Young as I like to think I am, I can still remember the days when hospitals had a subliminal military style discipline and a real sense of order. As soon as you walked onto the wards of a London teaching hospital, it became obvious that you had entered another world. Doctors and nurses occupied much more distinctive territory than they do today. In those dim and distant, pre-smart phone days your average clinician wouldn’t think about turning up on a ward round without a stethoscope and his regimental white coat.
Those days have gone. Somewhere in the late noughties, the government decided that white coats should become a thing of the past and that the future would be much better for it. I’m still not convinced they were right.
In the aftermath of this minor but momentous decision, standards of dress plummeted for junior doctors everywhere. Even at the time, a number of colleagues considered the decision a deliberate attempt to de-professionalise doctors but the official motivation had been something else: bacterial infection.
Ties and white coats were deemed a vector for unscrupulous bacteria and it was suggested that patients were being infected by white coat bourne spores. With hindsight, the actual evidence for this theory was tenous to say the least but I think that the people who suffered the most from it were the patients.
A lot of patients aren’t particularly young. Nor are they entirely with it. The elderly pick up on visual cues and the sight of a man in dark suit accompanied by a woman in navy blue and a younger doctor in a white coat was an easy image to get a grip on. It doesn’t really matter if you can’t remember a name or a face. The patients understood the hierarchy and they knew which opinion was the single most significant. The uniforms said it all and when a friend or relative visited the ward and wanted to know who to speak to, they could usually spot a doctor from a maintenance engineer quite easily. I remember as a junior doctor myself a neurosurgical patient passed this disparaging verdict on one of our then consultants: “he looked like someone who had come to do the gardening.” As I remember it, he was a good technician but even today, a lot of patients are looking for something more than that.
There are a lot of people walking up and down the corridor in a typical hospital ward and it’s a lot harder to figure out who is who than it used to be. Some microbiologists have openly stated that the infection risk associated with traditional dress codes has been wildly exaggerated.
There is no evidence that the white coat is a vehicle for the spread of infection, said Stephanie Dancer, a microbiologist at Hairmyres Hospital in East Kilbride. In contrast, “hand-touch contact, airborne delivery, environmental reservoirs, and human carriage are all implicated in transmission”.
In reality, The white coat has been a symbol of the medical profession since it was borrowed from laboratory workers in the mid-19th century. It was widely believed that the colour white would link the profession to such worthy concepts as purity and cleanliness. Many physicians have pointed out that no study has conclusively linked white coats with the spread of infection to patients. Recent evidence has shown that the bacterial load on coat sleeves is equivalent to that found on surgical scrub sleeves after 8 hours of hospital duties. In spite of this, it remains the recommendation of the NHS that healthcare workers should have a dress code of bare-below-elbows outfits. It would have been better to have a trial of the altered dress code for several years before insisting that it should be imposed nationally. By comparing the performance of different units with the old and the new we could have made a more objective judgment as to how best to proceed with modern medicine. No such work was ever done.
Remember that these machinations have implications that go far beyond the risk of bacterial infection. Something more than a mere aesthetic has been lost. The boundaries between clinician and managerial authority have been changed and neither the profession or the public have the same sense of confidence in who knows what or how things should be done.
Content provided by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth)
Medical Consultant, Orthopaedics and Trauma Surgery, James Paget, University Hospitals,
NHS Foundation Trust