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Editorial


The hospital has a new dress code for its vectors—er, doctors

Take off that necktie, put on a short-sleeved shirt, lose the wristwatch, leave your white coat home

November 2008 · Vol. 20, No. 11

Most patients prefer that physicians wear business, not informal, attire.1 To be specific, patients report that they prefer the following wardrobe touches for female physicians:

  • long sleeves
  • long dress or skirt (or a suit)
  • closed shoes
  • white coat.

For male physicians? Patients want

  • trousers
  • long-sleeve shirt (or a suit)
  • closed shoes
  • patterned tie
  • white coat.

Patients do not want to see you wearing a T-shirt, sandals, or shorts. Also, it’s interesting that patients positively regard a smiling and welcoming clinician. Keep that in mind.2

These are generalizations, of course. Taken together, patients and physicians contribute a range of perspectives on what constitutes proper attire for a clinician.

Having noted those survey findings, I want to alert you that we physicians in the United States may be—repeat, may be—on the verge of a major change in our clinical wardrobe because of recent official actions in the United Kingdom. But it’s concern over hygiene, not style, that has started winds of change blowing down the fashion runway.

But first: Reducing infection and cross-infection

Nosocomial infection is an important challenge in the hospital. The best approach to reduce the risk of nosocomial infection is to wash hands regularly or to use a hand disinfectant before and after you see every patient. In one study, a program of clinician education 1) increased the use of handwashing from 48% to 66% of patient contacts and 2) reduced the rate of transmission of methicillin-resistant Staphylococcus aureus (MRSA) by 50%.3 (Other effective hospital interventions include: meticulous cleaning of all surfaces; active surveillance of all high-risk patients for colonization or infection with MRSA; and barrier precautions.4)



What does hygiene have to do with what hospital medical staff wear on the job?

Wardrobe recommendations for that “new look”

In September 2007, United Kingdom Health Secretary Alan Johnson outlined a set of new interventions aimed at reducing the risk of hospital-acquired infection. These guidelines included:

  • a consensus recommendation that hospital clinicians wash their hands, or use a hand disinfectant, before and after seeing every patient
  • a novel recommendation that all clinicians dress “bare below the elbows.”

The hope is that being “bare below the elbow” will have a twofold result: Physicians will wash their hands more effectively, and nosocomial transmission of such organisms as MRSA and Clostridium difficile by shirt sleeves, long ties, and wristwatches will be prevented.

The new UK policy also bans long-sleeve shirts and the traditional long-sleeved white coat.5

Health Secretary Johnson did acknowledge that little scientific evidence supports this recommendation. But, he said, “informed common sense” and a pressing need to reduce nosocomial infections required the change.

Some regional UK health centers report a reduction in the rate of MRSA and C difficile colonization rates since the new dress code was implemented.

Basic black (listed)

The new UK hospital dress code says “No” to:

Wristwatches, hand jewelry. Wedding bands are exempt from the ban; this is perplexing, but it may be that they have few surfaces on which bacteria can colonize.

Long sleeves. The instruction to dress “bare below the elbows” is based on two beliefs:

  • anything with long sleeves limits one’s ability to effectively wash hands and wrists between patient contacts
  • long-sleeve cuffs can become colonized with bacteria.

Neckties. A number of studies have documented that ties—long ties and bow ties—can become contaminated with bacteria.6 In one study, 20% of 40 neckties worn by physicians were colonized with a substantial concentration of S aureus; one was colonized with MRSA.7 Unlike scrubs or white coats, ties are seldom laundered; in this study, physicians reported that they laundered their neckties about twice a year.

Other studies have also demonstrated that neckties can be colonized with bacteria8; so can lanyards and badges.9

The iconic white coat. Many patients and physicians see a white coat as a sign of professionalism—and believe that it improves hygiene.10 Paradoxically, white coats may actually be a source of cross-infection from one patient to another.11 In one study, the cuffs and pockets of a white coat were most likely to harbor bacteria. Coats that were frequently laundered had fewer bacteria than coats that were laundered infrequently.

Slaves to a new fashion?

Will UK wardrobe guidelines for clinicians become well-established and uniformly accepted there? Or will physicians in the United Kingdom eventually return to the traditional business dress and white coat that are also typical of physicians in the United States? And, if UK physicians do embrace a “bare below the elbows” dress code, I wonder: Will US physicians (and hospital regulatory agencies) be far behind?

References

1. Keenum AJ, Wallace LS, Stevens AR. Patients’ attitudes regarding physical characteristics of family practice physicians. South Med J. 2003;96:1190-1194.

2. Lill MM, Wilkinson TJ. Judging a book by its cover: descriptive survey of patients’ preferences for doctors’ appearance and mode of dress. BMJ. 2005;331:1524-1527.

3. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307-1312.

4. Peterson LR, Hacek DM, Robicsek A. 5 Million Lives Campaign. Case study: an MRSA intervention at Evanston Northwestern Healthcare. Jt Comm J Qual Patient Saf. 2007;33:732-738.

5. The traditional white coat: goodbye, or au revoir? [editorial] Lancet. 2007;370:1102.-

6. Biljan MM, Hart CA, Sunderland D, Manasse PR, Kingsland CR. Multicentre randomised double blind crossover trial on contamination of conventional ties and bow ties in routine obstetric and gynaecological practice. BMJ. 1993;307:1582-1584.

7. Ditchburn I. Should doctors wear ties? J Hosp Infect. 2006;63:227-228.

8. Dixon M. Neck ties as vectors for nosocomial infection. Intensive Care Med. 2000;26:250.-

9. Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. What’s hanging around your neck? Pathogenic bacteria on identity badges and lanyards. Med J Aust. 2008;188:5-8.

10. Gooden BR, Smith MJ, Tattersall SJ, Stockler MR. Hospitalised patients’ views on doctors and white coats. Med J Aust. 2001;175:219-222.

11. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ. 1991;303:1602-1604.

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