Should doctors hang up the white coats for good?

There are many raging controversies in medicine.  Physician attire, however, is almost never one of them.  There is but one exception:  the quintessential and ever-recognizable white coat.

The white coat has been a symbol of the medical profession since it was borrowed from laboratory workers nearly 200 years ago.  The white color, in fact, was chosen to associate physicians with purity and cleanliness.  But infection control buffs, like Philip Lederer, Infectious Diseases Fellow at Massachusetts General Hospital, who wrote a persuasive piece last year calling doctors to “hang up the white coats for good,” assert that the coats pose an astronomical infection risk.  Although no study has definitively demonstrated that the white coat tradition spreads infection to patients, intuitively, the idea makes sense.  We can culture all kinds of scary bacteria from the sleeves of white coats, which, in theory, could be transmitted to patients. We also know, or at least firmly believe, that doctors don’t launder their white coats often.  Invoking the parachute trial – the humorous imaginary randomly controlled trial examining the efficacy of using parachutes when jumping out of a plane – Lederer rebuffs those calling for hard evidence that white coats spread infection. Proof is superfluous and impractical; the concept just makes sense.  

So much sense, in fact, that many have advocated for a “bare-below-the-elbows” approach to doctors’ attire, a practice that has now become an official policy of the British National Health Service (ties, too, are a no-go).   Predictably, the policy has been met with resistance.

Indeed, the prospect of abandoning the white coat is highly problematic to many, and for good reason.  Important questions arise:  What would become of the famous “White Coat Ceremony” that 97% of medical schools still celebrate to welcome new students to the medical profession?  Without a white coat, how would doctors keep all aspects of their armamentarium – stethoscope, pager, reflex hammer, pens, notes, etc. – available at all times?  How would the New Yorker cartoonists portray doctors if white coats were banished?  

Trivialities aside, proponents of the white coat keenly note that those we serve – our patients – actually prefer us to keep our white coats on.  A 2013 study, in fact, found that 70% of patients surveyed preferred that their doctors wear white coats, particularly in the outpatient setting.  Even after these same patients were given information regarding the supposed risk of coat-carried infections, 87% still reported feeling comfortable with a doctor who wore one.  

But perhaps the most striking bit of evidence in favor of the white coat camp is that the act of wearing one may actually make us better doctors.  In a study conducted at the Kellogg School of Management at Northwestern University, researchers assigned a group of students to wear a white lab coat they were told belonged to a doctor.  They assigned a second group to wear street clothes, and a third to wear a white coat  they were told belonged to a painter.  On a test of sustained attention, the students wearing the doctor’s white coat outperformed the others substantially.   The authors describe the concept as “embodied cognition” That is, aspects of a person’s body beyond the brain can “play a significant causal or physically constitutive role in cognitive processing.”  In short, those who felt like a doctor acted like one.

Yes, my white coat may be contaminated with bacteria.  But isn’t the same true of the surface of my skin, and the clothes I wear?

By Nicole Van Groningen

@Nvangroningenmd