The Inconclusive Future of Healthcare's Most Prominent Symbol

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The healthcare industry is, by nature, an innovative field. Researchers are constantly studying and developing cutting-edge tools and technology to advance the collective knowledge and capabilities of the field.

However, not all facets of healthcare are so forward-looking. While developments in surgical techniques and advanced imaging systems are being refined for the future, the presence and symbolism of the physician white coat remain firmly rooted in the past, unchanged for the past two centuries.

Physicians and white coats have gone arm in arm since the late 19th century when physicians starting wearing white clothing to signify the sterility of medicine, prior to which they donned all black to reflect the seriousness and formality of the practice. Since then, the white coat has been one of the most prominent symbols of the healthcare industry, worn by clinicians as a mark of professionalism and a nod to the historic origins of the profession.

It is ironic, then, that recent studies and research suggest the white coat, this historically rooted symbol of purity, may be contributing to the spread of healthcare-associated infections.

An unsuspecting infection risk
In February, the Society of Healthcare Epidemiology in America released an expert guidance paper in Infection Control and Hospital Epidemiology suggesting certain healthcare personnel apparel may play a role in the transmission of HAIs. To remedy the issue, the guidance suggests clinicians go "bare below the elbows" and remove white coats when interacting with patients in non-operation, acute-care settings. In fact, the guidance proposes, if feasible, eliminating the white coat altogether.

Gonzalo Bearman, MD, professor of internal medicine and associate hospital epidemiologist at the Virginia Commonwealth University Health System in Richmond, and lead author of the study, says while there is no concrete evidence correlating white coats and HAIs, a relationship between the two is not out of the realm of possibility.
 
"There is no definitive slam dunk evidence that apparel causes an HAI," Dr. Bearman says. "There's a biological, theoretical plausibility that it could be involved in the cross transmission process. Modifications in apparel are based on biological plausibility, are unlikely to cause harm and should be voluntarily employed as an infection prevention adjunct" in addition to other evidence-based protocols, he says.

With the rising costs and prevalence of HAIs plaguing the healthcare system, hospitals really have nothing to lose by taking a seemingly simple precaution such as removing a white coat, perhaps indefinitely.

Who's who in the hospital?
But it isn't so easy to simply cut the white coat out of the hospital scene. One has to consider, for example, the history and symbolism that the white coat carries, woven into its pockets along with the stethoscope and prescription pad.

"The whole issue of healthcare attire is still an emotionally charged issue," Dr. Bearman says. "The use of a white coat is steep in tradition and culture….Patients expect to see a doctor in a white coat."

Perhaps it is this patient expectation that initiated a common occurrence during the residency training of Barbara Bergin, MD, orthopedic surgeon at Austin-based Texas Orthopedics.

"If I did not distinguish myself by wearing a white coat, I would get stopped," Dr. Bergin says, referring to her residency training where she was the only female orthopedic resident. "It was frequent, in the hallway, in patients' room, [I would] be asked to perform nursing duties."

Not that Dr. Bergin had any issue with being asked to do so. It simply was not part of her responsibilities, and responding to the request would keep her from her physician duties, she says.

"Emptying bed pans is not usually in my job description," Dr. Bergin says. "I did it a few times, but my attending got mad."

The issue here, according to Dr. Bergin, is a breakdown in efficiency of care and a setback in patient care quality. If patients can't determine who is who in the hospital, they won't know who to turn to for help.

"You need to know who is going to be able to help you. If a nurse is standing out in the hall and a person is bleeding, a patient needs to know who to ask for help…. You're going to waste time asking other people for assistance," Dr. Bergin says. "It's best to leave doctors to do their doctoring work and nurses to do their nursing work and orderlies to do their orderly work."

Patient expectations
Clinician identification aside, eliminating the white coat for patient safety reasons brings rise to other concerns, notably patient experience. Patient experience is a key quality metric for hospitals, so it's difficult to ignore the research suggesting patients prefer the white coat. The SHEA guidance paper analyzed 26 other studies on patient perception and preference of physician attire, and the literature suggests patients prefer formal, standardized attire, including the white coat.

Dr. Bergin acknowledges this patient preference, noticing patients' affinity for the white coat in her own practice.

"There is a level of respect that goes with seeing a white coat," Dr. Bergin says. "If I walk into a room and I have scrubs on, they might not know who I am. If I walk into a room with a white coat, they assume I am a doctor."

Healthcare's checks and balances
So we find ourselves in this delicately balanced three-ring circus. In one ring, researchers are concerned with the role the white coat plays in infection control. Another ring tests the boundaries of clinician identification. Finally, patient preference and satisfaction constantly hang overhead.

The balance is so fine because none of these three elements trumps the other in terms of importance. In the end, all three fundamentally come down to patient safety and satisfaction, which is arguably the essence of healthcare.

As it stands, a future action plan remains inconclusive. Change won't come readily because it requires an alteration in mindset for all parties involved, including clinicians and patients.

"There are some cultural barriers to overcome before a change in apparel," Dr. Bearman says.

Yet we still look to the future. Perhaps future studies on HAI transmission by apparel will reveal a link between the two. Perhaps the next generation of physicians won't be so attached to their coats. Perhaps patients and consumers won't inextricably link images of physicians with white coats.

Researchers will continue to innovate and discover advancements in medicine, and the industry will undoubtedly evolve and progress. As we keep our eyes looking forward to new clinical developments, the cultural shift in perception of the white coat is going to be more heavily burdened by the weight of history.

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