Is it time for an evidence based uniform for doctors?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8286 (Published 18 December 2012) Cite this as: BMJ 2012;345:e8286
- Rhys Clement, specialist trainee year 4 in trauma and orthopaedics
- Correspondence to: R G E Clement
Hippocrates advised that doctors should “be clean in person, well dressed, and anointed with sweet smelling unguents.”1 Although this remains sound advice, the concept of acceptable attire for doctors is constantly evolving. Two hundred years ago doctors wore formal attire for all clinical activity, including surgery, because they had no idea that their clothing could transmit infection. The demonstration of micro-organisms by Pasteur revolutionised the way people thought about infection and paved the way for Lister’s concept of antisepsis that has shaped our modern approach towards infection control.
However, Lister did not recognise clothing as a source of infection and continued to operate in formal attire. MacEwan, a student under Lister who became professor of surgery in Glasgow, is credited with introducing the sterile surgical gown. White coats made their appearance on wards and in clinics during the 20th century and are an iconic symbol of the medical profession. They were cited as a defining factor in the emerging role of hospital based care and the acceptance of the sick role outside of the home.2
The white coat remained the status quo until 2007, when the Department of Health (DOH) released dress code guidelines that forced doctors to remove their white coats, jackets, ties, and watches and roll up their sleeves.3 These guidelines were based on the findings of two literature reviews known as TVU1 and TVU2,4 5 which were commissioned and funded by the DOH “to inform policy development.”
Critics argue that evidence to support the new dress code is lacking, and the conclusions of TVU1 and TVU2 suggest there may be some merit in their argument.6 7 8 TVU1 stated that “the hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by the existing evidence” and TVU2 found “no good evidence to suggest uniforms are a significant risk.” TVU2 further warned “It is essential that the evidence is considered in a balanced way and not over-emphasised in the development of uniform policy.”
In 2010 the DOH updated the guidelines with the introduction of three key objectives: patient safety, public confidence, and staff comfort, but the guidance stopped short of introducing a uniform for doctors.9
The ideal attributes of a uniform for doctors
I wanted to create an ideal uniform based on existing literature. Starting with the DOH’s objectives of patient safety, public confidence, and staff comfort I drew up a list of the “ideal attributes” of a new uniform (box). I considered each objective in turn and attempted to fulfil as many of the “ideal attributes” as possible with my proposals, which are backed up with evidence that I have collected through a wide variety of sources in a non-systematic way.
Desirable attributes of a new uniform
Reduces airborne spread of infection
Decreases bacterial load of wearer
Allows efficient hand hygiene (bare below elbows?)
Appearance that inspires trust
Easy to identify practitioner
Instils confidence that uniform is hygienic
Non-iron, allowing easy transport to and from work
Doesn’t restrict movement
Additional benefits for the wearer, such as safety features
Effective hygiene and prevention of infection are absolutes in all healthcare settings, and my design of the new uniform gives priority to this objective. Several aspects of the uniform could reduce transmission of bacterial, viral, and fungal pathogens.
Some commensal micro-organisms have pathogenic potential. Human sweat is an excellent culture medium for bacteria,10 and clothes that are impregnated with sweat rapidly become colonised.11 The build up of sweat could be limited by a new uniform that uses high wicking fabrics to move sweat away from the body.12 13 Impregnating nano sized particles of silver into the fabric could go one better and give the uniforms a bactericidal function.14 For these modern materials to act effectively they must be in direct contact with the skin. Problems arise if there are any “breaks” in the material where the effect is lost and bacteria can spill out. An “all in one” design for the new uniform would minimise this phenomenon.
Limiting airborne spread of infection
Infectious organisms such as meningococci, mycobacteria, and the influenza virus can be transmitted through droplets contact when a person coughs or sneezes.15 Facemasks can limit such transmission but have a negative impact on the patient-doctor interaction. Facemasks should therefore be worn only in high risk areas, such as intensive care units.15 16 17
The faecal-oral route of infection can spread cholera, hepatitis A, polio, rotavirus, and salmonella.18 The spill of bacteria and micro-organisms that occurs as a result of flatulence is a realistic source of infection. Flatulence is a taboo subject and little research has gone into its role in the spread of infection. However, a light hearted experiment by “the naked scientists” showed that petri dishes exposed to flatulence cultured Escherichia coli.19 An additional layer of clothing overlying the groin and perineum that incorporates microbial filters could block this route of infection. Patents already exist for antimicrobial underwear, and these could be introduced without delay.20 21 The filters could cause localised irritation if worn under clothes and would limit the movement of sweat away from the perineum, leading to an increase in bacterial load in this area. These problems would be solved by wearing this additional layer as an over garment.
Bare below the elbows?
The necessity to be “bare below the elbows” is possibly the most contentious part of the DOH guidelines. The policy was introduced after two papers (one published in the 1991 Christmas BMJ) found that white coats became contaminated progressively as they were worn. However, most of the organisms isolated were non-pathogenic environmental bacteria or skin commensals that probably came from the wearer.22 23 Critics of the policy have jokingly suggested that it may have emanated from a misinterpretation of a finding in TVU1 that “uniforms have been found to become frequently contaminated below the waist!”
Although the policy is often mocked, there is an emerging body of evidence that clothing can act as a fomite. Watches, ties, and shirt cuffs have all been shown to harbour bacterial pathogens.24 25 Another proposed advantage is that strict hand washing guidelines are less likely to be adhered to by those who are non-compliant. The evidence in support of this claim is questionable. It has been shown that there is no difference in the bacterial flora of the hands of compliant and non-compliant staff and no increase in pathogenic bacteria isolated from glove sweat of those wearing rings compared with those without them.10 11
The policy seems to be theoretically sensible, but more evidence is needed in support of it. An important yet unanswered question is whether the lack of a barrier in short sleeved shirts increases the airborne spread of bacteria from the armpits, where pathogens such as meticillin resistant Staphyloccocus aureus are prevalent.26 Only time will tell if critics of the policy will one day be compared with Pierre Pachet, the professor of physiology at Toulouse who famously said that “Louis Pasteur’s theory of germs is ridiculous fiction.”
People’s perceptions of the standards of care they receive are influenced by the way staff dress.
Maintaining a professional image
Since the bare below the elbows dress code was introduced, a flurry of publications have shown that patients prefer formal attire.6 7 8 27 However, patients vary greatly in what they consider acceptable, and the evidence points to a balanced distribution of opinions.28 29 30 Scrubs are considered by the general public to be the most hygienic option,31 so a uniform that resembles them would be appropriate.
The colour of a uniform can have a subtle psychological effect on the patient’s feelings towards the practitioner.32 Light blue and green have traditionally been used for medical uniforms because they have a soothing and calming effect. It is important that there is a clear distinction between staff working in exposure prone areas, such as the operating theatre, who should not wear their uniforms elsewhere. A simple choice would be blue uniforms for wards and clinics and green for high risk environments such as intensive care and theatre.
Patients should be able to identify different members of staff quickly and easily.33 With an ageing population the number of visually impaired patients is rising and most of these people would not be able to read an ID badge.34 35 If neckties are to be banned because of the risk of infection then the same should apply to ID badges.36 I therefore recommend incorporating an identification system directly into the uniform. A single large letter on the chest that identifies the specialty of the practitioner, such as “A” for anaesthetist or “D” for doctor, could be seen by visually impaired patients from a distance and would be ideal.
The choice of fabric outlined above should ensure that the uniforms are comfortable, non-allergenic, and allow unrestricted movement. Uniforms would not require ironing, which would reduce labour and allow easy transport to and from work.
The spread of serious infections including HIV and hepatitis B to healthcare professionals via accidental needle stick inoculation is well documented.37 Despite high profile educational initiatives the rate of needle stick injuries is still high—more than 80% of surgeons in training have had one at some point.38
One proposed factor in needle stick injuries is loss of concentration due to interruptions from other staff. The nursing profession has successfully introduced bright red “do not disturb” tabards for use during their drug rounds, when mistakes can be life threatening.39 Doctors could similarly be protected by a highly visible item of uniform that provides “Care And Protection during Exposure prone procedures.” Because of its function, I will simply refer to this item as a CAPE for short. To limit the impact on the clinical activity and not interfere with the sterile field I recommend that a CAPE should be deficient anteriorly.
I believe that there is enough evidence to support a transition to the uniform that I have proposed and I hope that it is adopted in the next update of the Department of Health’s dress code policy⇓.
Cite this as: BMJ 2012;345:e8286
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.