The White Coat

Last week one of my patients brought his 5-year-old granddaughter with him to his appointment.  When I came into the exam room the child was visibly disappointed to see me and told her grandpa that she didn’t believe I was a doctor because I wasn’t wearing a white coat.  Once I retrieved my lab coat and returned to the room I got a clear nod of approval from my young critic (this is why I didn’t go into pediatrics—way too much pressure).

I really don’t like white lab coats.  They’re hot, they snag on doorknobs and edges of desks, and stuff dumps out of the waist pockets when I sit down.  Moving around the ICU in a long lab coat is like touring a china shop in a poorly tailored trench coat.  Add to this my own perception that with my thin frame I can’t really pull off the “doctor look” in a lab coat. I look more like somewhat trying to look like a doctor—like I’m going to work wearing a Halloween costume.  Some patients also react somewhat unfavorably to the attire.  White coat hypertension is a well documented syndrome of artificially elevated blood pressure in patients nervously sitting in front of their white-clad doctor, and my heart patients don’t need any more problems than they already have.

In training I relied heavily on the oversized pockets as a repository for my many medical handbooks, but the invention of the PDA and smart phone—with their ability to provide immediate electronic access to a library of reference sources—has largely obviated my need for pantry-sized pockets.

When I started medical school I was pretty excited to get my first lab coat.  Wearing the white coat around the hospital as a third-year student was a pretty big deal.  Nowadays medical schools have managed take this one step further with “white coat ceremonies” where earnest professors robe their medical trainees in the holy white vestiges of Hippocrates (I graduated medical school a few years before this silly trend began).

The white coat has been the visible symbol of medical authority ever since the medical profession hijacked it from their scientific colleagues over a century ago.  Prior to formalized medical training in the United States the early practitioners of medicine were viewed as quacks and mystics and needed a visible display of their new trend toward healing through the scientific method.

The public has come to expect their medical professionals to be wrapped in white cotton, largely thanks to the image of the fictionalized physician that has been formally codified in every movie and television show from General Hospital to Gray’s Anatomy.  Marcus Welby adhered strictly to school of formal fashion and would have never deigned to appear clad only in khakis and a polo shirt.  Outside the world of Dr. McDreamy the reality is not much different: scientific studies on the subject confirm the theory that patients perceive their physician to be more competent and capable if he or she appears in a white coat.

Well, times may be changing.  It turns out that the white coat is coming under increasing scrutiny and criticism, and not just by people like me whose complaints are more of a sartorial nature.  Numerous reports in the last decade demonstrate that the lab coat—with its oversized sleeves and overcoat design—tend to make more contact with our patients than we’d like.  Resourceful microbiologists and infectious disease specialists have taken to culturing the garment and finding a frightening world of microbiological flora that we are dragging from patient to patient.

In one such study researchers randomly sampled the lab coats of dozens of attendees at medical and surgical grand rounds at a large academic hospital.  After culturing the sleeves of these residents, interns and medical students, they found that 23% of the 149 volunteers were contaminated with Staph aureus, a common but problematic pathogen that is currently to blame for many hospital-acquired infections.  A significant 18% of white coats were colonized with the far more virulent and difficult-to-treat multi-drug resistant variety.  You can find public restrooms more sanitary than this.

Just last summer the American Medical Association voted on a motion to recommend banning the venerable white coat from use inside hospitals.  They cited numerous studies (like the one above) that show that we practitioners could cut back on the rate of hospital infections if we’d just give up our Typhoid Mary attire (oh, and do a better job of washing our hands—but that’s another story).  If they follow through with their recommendation they will be taking a cue from our relatives across the pond who’ve already banned white coats as part of their far more aggressive “bare below the elbows” campaign than prohibits coats, long sleeves, watches, jewelry, and neckties. (Neckties?  Sure.  According to one study half the ties worn by doctors in one New York City hospital contained bacteria known to cause hospital infections.  And how often do you send your ties out for laundry?)

So, are white coats destined to suffer the same fate as nursing capes and fade into extinction?  Despite my personal fashion and comfort misgivings and the dire warnings from our microbiology colleagues, I actually hope not.  Somewhere we have to find a compromise between the science of antisepsis and a respect for tradition and image.  For, like the child in my office, when I see physicians sporting well-pressed, bright white coats I have to admit they look wiser, more capable, and, in the end, more doctorly.