White coats in hospitals
We were astounded to read that the Department of Health has decided to ban doctors from wearing white coats from 1st January 2008 on the grounds that white coats represent a risk factor for hospital cross- infection (1). The package outlined by Alan Johnson, Health Secretary, on the 17th September on the subject of clothing describes a "bare below the elbows" dress code (“short sleeves, no wrist watch, no jewellery and allied to this the avoidance of ties when carrying out clinical activity”), and includes the dictat that “traditional doctors' white coat will not be allowed”.
What is the evidence for this? Well, it is impossible to say because this policy is based on two “wide-ranging literature reviews carried out by Thames Valley University”, reviews which are as yet unpublished. Surely, the reviews should have been made available first for discussion and debate? We doubt if the evidence is that convincing as in total contradiction to the ban on white coats, the first conclusion reached by the Working Group states that “There is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection”, and the report ends with “it seems unlikely that uniforms are a significant source of cross-infection”.
The policy document considers it good practice for medical staff to “Wear short-sleeved shirts/blouses and avoid wearing white coats when providing patient care” because “Cuffs become heavily contaminated and are more likely to come into contact with patients”. Presumably this conclusion is based on the finding that bacteria such as Staphylococcus aureus can be isolated from a quarter of white coats (2). Yes, but these were white coats which had been worn for up to 8 weeks and not changed daily as should be the case. Why? Because hospitals no longer provide clean white coats as a matter of routine with the result that it is a struggle to get hold of one.
But may be we should not be astounded. Dirty hospitals and high bed occupancy rates would cost money to sort out, whereas “bare below the elbows” is a cheap sound-bite which saves money. Hospitals will not have to provide white coats just like they no longer launder nurses’ uniforms. And yet this ignores the advantages of white coats/name badges in terms of ease of identification, for carrying books and equipment, as protection against spillage of bodily fluids, and the simple fact that it is considerably easier to change a dirty white coat than one’s suit or dress. Most hospital patients in the UK prefer doctors to wear a white coat (3,4), and as far as we are aware, white coats ± scrubs are universal in most countries (5).
White coats should not be banned in hospitals. Yes, change to a plastic apron when examining patients, especially those with wound sites, and wash your hands before and after seeing a patient, but also insist that the hospital provides you with a clean white coat every day.
1. Uniforms and workwear: An evidence base for developing local policy. Department of Health, September 2007.
2. Wong D, Nue K, Hollis P. Microbial flora on doctors’ white coats. Br Med J 1991;303:1602-4.
3. Tiwari A, Abesinghe N, Hall A, Perera P, Ackroyd JS. Should doctors wear white coats? The patient’s perspective. J Eval Clin Pract 2001;7:343- 5
4. Douse J, Derrett-Smith E, Dheda K, Dilworth JP. Postgrad Med J 2004;80:284-6.
5. Major K, Hayase Y, Balderrama D, Lefor AT. Attitudes regarding surgeons’ attire. Am J Surg 2005;190:103-9.
Competing interests: None declared
Competing interests: No competing interests