I wore lab coats for years and never gave it a thought and always a tie. I told house staff you "dress up" to show respect for your patients. Then I went to California and was shown ties were passè, at best. So now my daily uniform is a dress shirt and a sport coat. That item alone says I'm a senior physician who is a professional, not their tiktok buddy.
Truth be told I have sometimes seen the first couple of Saturday patients in my bicycle kit when I've ridden the 8 miles to work and I'm late. My patients accept me. They're a pretty open minded lot.
From a nosocomial standpoint- basic hygiene regardless of "outfit"
Who cares if it's a shirt with checkers, a pristine white coat or scrubs. When the mouth opens if empathy, curiosity, patience and medical knowledge roll out you could be wearing a bikini or a speedo.
I abandoned the white coat in fellowship mostly--for some reason it caused neck aches from the weight of garbage in may pockets, etc. I've never worn a white coat in private practice. They still hang in the office perfectly starched. I opted initially for long sleeve button down shirts (sleeves rolled 3/4) with slacks until the pandemic. I switched to hospital scrubs for a while before wearing purchased scrubs shortly after. One of these days I may turn back--but man it makes decisions in the morning exceedingly easy. Patients haven't complained. So be it.
I continually learn from you with every post. You are a gift to us all. When I was doing a rotation at a big hospital conglomerate, we all had to wear white coats whether we were just head shrinkers like me or the surgeons themselves. When somebody referred me as doctor, I told them, “I’m not that smart, for real!” Most patient responded readily to that one.
My (possibly irrational) pet peeve is the doctor wearing the stethoscope carefully and symmetrically draped around the neck. This suggests a form of artifice that I find somewhat disturbing. I also ditched the white coat after residency and fellowship training. Never wore a tie---uncomfortable and pointless. Always carried the stethoscope in my pocket. All the talk about clothing carrying infectious particles seems pretty stupid. On surrogate endpoints---almost all are used to justify medicinal treatment for something that isn't even a disease.
As Dr. Prasad has eloguently claimed, physicians are exposed to "piss and shit" all day. Does it really take robust medical literature to convince you that wearing a clean white coat is better than a dirty one?
Adam's charming commentary on an issue that has a teeter-totter of arguments pro and con and NO data either way is written by someone who has not been mistaken for the nurse.
One of my early experiences of this misunderstanding was in the ER when I ducked into a cubicle to do an admission H & P on a new patient assigned to my team. Before I could open my mouth the patient said "finally, I hit the call button 20 minutes ago, I have to get off this bedpan." I was wearing scrubs and a white coat that said Dr. and a hospital ID badge that said Doctor; but patient was expecting help with the bedpan. So, I took off my white coat, put on gloves and a gown and helped with the bedpan. Then I introduced myself, checked on the identity of the patient and did the H & P. It was awkward, especially for my patient but, we managed. If I hadn't given him every cue to identify me as an MD it would have been worse. If I'd left him on the bedpan while I went to find a nurse it would have been worse.
This happened 40 years ago when women were still ~30% of the practicing physician workforce but the female MD mistaken for nurse tropes persist. My daughter her finished IM residency a year ago and has her own stories to tell.
White coats help patients identify the doctor, they help to decrease confusion but, they are a symbol of authority and can engender fear. Each doctor-patient relationship is a little different but in all of them the doctor is the medical authority and in some of those relationships a white coat helps to establish and/or reinforce that role.
Your story reminds me of one: I am an RN. In certain areas of Iowa we have significant Amish populations. Depending on the severity of illness, they will occasionally be admitted to a hospital. A very sweet older Amish lady determined that I was the doctor's wife-I didn't even get to be a nurse! HA!
Another good point. Thanks. What you say is true, I get referred to as "doctor" when I walk in on non clinical days in a sweatshirt, jeans, and a baseball cap.
I love to see a surgeon, in an office visit, (male or female) with a meticulous manicure and crisp white shirt. In general, a bit better than well groomed. It is an outward sign of attention to detail and cleanliness in someone who is shortly going cut you open and plunge their hands into your body. Wearing a clean white garment, either the coat or the shirt, signals to the patient that the surgeon doesn’t mess up. They aren’t afraid to eat spaghetti in white with no spills or splashes. Just a silly signal to the patient maybe, but it works.
Environmental microbiology (culturing clothing, walls,countertops etc,) was debunked in the seventies but somehow refuses to die! I still follow the ‘rule of 5’ when making connections between fomites and resultant infections.
Would love to be pointed in the direction of this debunking if you don’t mind. I’m an ID fellow, and while I love my job and my patients, I find the whole IPAC world confusing.
The use of the “space suits” that became popular in intensive care units for treating patients with COVID-19 — but above all, the therapeutic nihilism that still persists in managing this condition — made me question whether we are witnessing the twilight of the white coat, the once-distinctive herald of the medical profession.
One could argue that clothing, regardless of its type, is a “risk factor” for nosocomial infection — which is the objective outcome variable here — particularly due to the microbial load carried from cafeterias and various wards on cuffs, elbows, and pockets, which are transferred and exchanged daily. A sterilized gown stays sterile for about 8 minutes after being worn. Ha ha.
This matter of medical attire is riddled with arbitrary decisions, often made by someone with neither objective nor subjective criteria. Have you ever wondered why the medical coat is white and not some other color? Or why, after the Vietnam War, surgical attire was dyed green? Where is the hard-outcomes evidence justifying that the Mayo surgical scrubs have become the de facto “proxy uniform” for healthcare workers worldwide?
I’ve explored this and related tensions in an essay (apologies, it’s in Spanish), “The Dusk of the White Coat”, which you can find at the link below. Ultimately, the problem is not the clothing, but the ethical essence of the medical profession — which, it seems, we have perhaps lost irretrievably.
“Even if you dress a monkey in silk, it’s still a monkey.”
After a couple of decades of wearing long-sleeve shirts with ties and a long white coat I stopped wearing ties after reading that they carried high bacterial loads. I wasn't necessarily convinced that my ties were infecting patients but I had lost my appetite for wearing them and used that as an excuse. About 10 years later I mostly stopped wearing the white coat. The white coat served as a reservoir for things I felt I needed to have with me (hospital lists, references, stethoscope, ID etc.) but I started putting the stethoscope around the neck, realized I didn't need anything else and felt liberated going whitecoatless.
Since Dr Cifu’s post is specifically about surrogate outcomes, I feel obliged to point out that that systematic review only documents evidence of bacterial *colonization* of sleeves, ties etc. This seems to me like a textbook definition of a bad surrogate outcome. After all, if the various fomites were contaminated with MRSA etc, where did that come from? Presumably the hospital environment! And where does the patient spend all their time, regardless of their doctor’s attire? The hospital environment!This kind of colonization data only reaches to the level of a bioplausibility argument with regards to causation of nosocomial infections, therefore only really convinces me to do what is already standard practice: sanitize anything that touches the patient directly (ie wash my hands - hardly earth shattering- and make an effort to sterilize my stethoscope).
I’m on mobile so I don’t have full text access but even the abstract acknowledges that “Four studies evaluated for possible connection between healthcare personnel contaminants and clinical isolates with no unequivocally direct link identified.”
When attending wards, I give out ‘points’ to hospital teams of learners if they can agree to collectively wear less than 2 colors of scrubs on rounds. It’s rare these points are awarded.
couldn't agree with you more. Most of our folks now, from resident through sometimes attending wear scrubs. So do many others on rounds making it hard to tell who I am talking with. Perhaps that is the point...
Stopped wearing scrubs 3 years ago. Everyone from the housekeeper to the CEO wears scrubs. I wear jeans every day with my white coat. Only one in the hospital. No positive cultures yet. 😳
I wore lab coats for years and never gave it a thought and always a tie. I told house staff you "dress up" to show respect for your patients. Then I went to California and was shown ties were passè, at best. So now my daily uniform is a dress shirt and a sport coat. That item alone says I'm a senior physician who is a professional, not their tiktok buddy.
Truth be told I have sometimes seen the first couple of Saturday patients in my bicycle kit when I've ridden the 8 miles to work and I'm late. My patients accept me. They're a pretty open minded lot.
From a nosocomial standpoint- basic hygiene regardless of "outfit"
Who cares if it's a shirt with checkers, a pristine white coat or scrubs. When the mouth opens if empathy, curiosity, patience and medical knowledge roll out you could be wearing a bikini or a speedo.
I abandoned the white coat in fellowship mostly--for some reason it caused neck aches from the weight of garbage in may pockets, etc. I've never worn a white coat in private practice. They still hang in the office perfectly starched. I opted initially for long sleeve button down shirts (sleeves rolled 3/4) with slacks until the pandemic. I switched to hospital scrubs for a while before wearing purchased scrubs shortly after. One of these days I may turn back--but man it makes decisions in the morning exceedingly easy. Patients haven't complained. So be it.
I would rather wear a dirty white coat, than the clean sport coat of the CEO and his attorney.
I continually learn from you with every post. You are a gift to us all. When I was doing a rotation at a big hospital conglomerate, we all had to wear white coats whether we were just head shrinkers like me or the surgeons themselves. When somebody referred me as doctor, I told them, “I’m not that smart, for real!” Most patient responded readily to that one.
🙏
How about black coats which were commonly worn prior to Pasteur?
They showed a lot of the dr’s experience in terms of pus and blood stains.
The problem w/ white coats/ties/mechanical watches is that they mostly don’t stain leaving the dr. looking like they’re inexperienced.
Also, don’t assume we all mourn Prasad. He’s firmly in the red, and now supports the trump agenda.
My (possibly irrational) pet peeve is the doctor wearing the stethoscope carefully and symmetrically draped around the neck. This suggests a form of artifice that I find somewhat disturbing. I also ditched the white coat after residency and fellowship training. Never wore a tie---uncomfortable and pointless. Always carried the stethoscope in my pocket. All the talk about clothing carrying infectious particles seems pretty stupid. On surrogate endpoints---almost all are used to justify medicinal treatment for something that isn't even a disease.
As Dr. Prasad has eloguently claimed, physicians are exposed to "piss and shit" all day. Does it really take robust medical literature to convince you that wearing a clean white coat is better than a dirty one?
Adam's charming commentary on an issue that has a teeter-totter of arguments pro and con and NO data either way is written by someone who has not been mistaken for the nurse.
One of my early experiences of this misunderstanding was in the ER when I ducked into a cubicle to do an admission H & P on a new patient assigned to my team. Before I could open my mouth the patient said "finally, I hit the call button 20 minutes ago, I have to get off this bedpan." I was wearing scrubs and a white coat that said Dr. and a hospital ID badge that said Doctor; but patient was expecting help with the bedpan. So, I took off my white coat, put on gloves and a gown and helped with the bedpan. Then I introduced myself, checked on the identity of the patient and did the H & P. It was awkward, especially for my patient but, we managed. If I hadn't given him every cue to identify me as an MD it would have been worse. If I'd left him on the bedpan while I went to find a nurse it would have been worse.
This happened 40 years ago when women were still ~30% of the practicing physician workforce but the female MD mistaken for nurse tropes persist. My daughter her finished IM residency a year ago and has her own stories to tell.
White coats help patients identify the doctor, they help to decrease confusion but, they are a symbol of authority and can engender fear. Each doctor-patient relationship is a little different but in all of them the doctor is the medical authority and in some of those relationships a white coat helps to establish and/or reinforce that role.
Your story reminds me of one: I am an RN. In certain areas of Iowa we have significant Amish populations. Depending on the severity of illness, they will occasionally be admitted to a hospital. A very sweet older Amish lady determined that I was the doctor's wife-I didn't even get to be a nurse! HA!
Another good point. Thanks. What you say is true, I get referred to as "doctor" when I walk in on non clinical days in a sweatshirt, jeans, and a baseball cap.
Which means our value is between the ears and not what we clothe our body in.
I love to see a surgeon, in an office visit, (male or female) with a meticulous manicure and crisp white shirt. In general, a bit better than well groomed. It is an outward sign of attention to detail and cleanliness in someone who is shortly going cut you open and plunge their hands into your body. Wearing a clean white garment, either the coat or the shirt, signals to the patient that the surgeon doesn’t mess up. They aren’t afraid to eat spaghetti in white with no spills or splashes. Just a silly signal to the patient maybe, but it works.
Sarah of course is correct ☑️
Environmental microbiology (culturing clothing, walls,countertops etc,) was debunked in the seventies but somehow refuses to die! I still follow the ‘rule of 5’ when making connections between fomites and resultant infections.
Would love to be pointed in the direction of this debunking if you don’t mind. I’m an ID fellow, and while I love my job and my patients, I find the whole IPAC world confusing.
Hello Dr. Cifu,
The use of the “space suits” that became popular in intensive care units for treating patients with COVID-19 — but above all, the therapeutic nihilism that still persists in managing this condition — made me question whether we are witnessing the twilight of the white coat, the once-distinctive herald of the medical profession.
One could argue that clothing, regardless of its type, is a “risk factor” for nosocomial infection — which is the objective outcome variable here — particularly due to the microbial load carried from cafeterias and various wards on cuffs, elbows, and pockets, which are transferred and exchanged daily. A sterilized gown stays sterile for about 8 minutes after being worn. Ha ha.
This matter of medical attire is riddled with arbitrary decisions, often made by someone with neither objective nor subjective criteria. Have you ever wondered why the medical coat is white and not some other color? Or why, after the Vietnam War, surgical attire was dyed green? Where is the hard-outcomes evidence justifying that the Mayo surgical scrubs have become the de facto “proxy uniform” for healthcare workers worldwide?
I’ve explored this and related tensions in an essay (apologies, it’s in Spanish), “The Dusk of the White Coat”, which you can find at the link below. Ultimately, the problem is not the clothing, but the ethical essence of the medical profession — which, it seems, we have perhaps lost irretrievably.
“Even if you dress a monkey in silk, it’s still a monkey.”
https://revistasum.umanizales.edu.co/ojs/index.php/archivosmedicina/article/view/4069
Thanks for the recommendation!
Of course, with the greatest pleasure!
After a couple of decades of wearing long-sleeve shirts with ties and a long white coat I stopped wearing ties after reading that they carried high bacterial loads. I wasn't necessarily convinced that my ties were infecting patients but I had lost my appetite for wearing them and used that as an excuse. About 10 years later I mostly stopped wearing the white coat. The white coat served as a reservoir for things I felt I needed to have with me (hospital lists, references, stethoscope, ID etc.) but I started putting the stethoscope around the neck, realized I didn't need anything else and felt liberated going whitecoatless.
Of course the stethoscope (along with the iPad and numerous other items) has been implicated in disease transmission. (https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/abs/healthcare-personnel-attire-and-devices-as-fomites-a-systematic-review/E37A68FBE905FEE4B2330EF90A942215)
Since Dr Cifu’s post is specifically about surrogate outcomes, I feel obliged to point out that that systematic review only documents evidence of bacterial *colonization* of sleeves, ties etc. This seems to me like a textbook definition of a bad surrogate outcome. After all, if the various fomites were contaminated with MRSA etc, where did that come from? Presumably the hospital environment! And where does the patient spend all their time, regardless of their doctor’s attire? The hospital environment!This kind of colonization data only reaches to the level of a bioplausibility argument with regards to causation of nosocomial infections, therefore only really convinces me to do what is already standard practice: sanitize anything that touches the patient directly (ie wash my hands - hardly earth shattering- and make an effort to sterilize my stethoscope).
I’m on mobile so I don’t have full text access but even the abstract acknowledges that “Four studies evaluated for possible connection between healthcare personnel contaminants and clinical isolates with no unequivocally direct link identified.”
Thoughts?
Agree.
When attending wards, I give out ‘points’ to hospital teams of learners if they can agree to collectively wear less than 2 colors of scrubs on rounds. It’s rare these points are awarded.
couldn't agree with you more. Most of our folks now, from resident through sometimes attending wear scrubs. So do many others on rounds making it hard to tell who I am talking with. Perhaps that is the point...
Stopped wearing scrubs 3 years ago. Everyone from the housekeeper to the CEO wears scrubs. I wear jeans every day with my white coat. Only one in the hospital. No positive cultures yet. 😳