The return of the white coat?
Authors: Oliver Ellis
Publication date: 01 Sep 2010
Medical uniform is making a comeback. Oliver Ellis investigates
Some hospitals in the United Kingdom are implementing compulsory uniforms for doctors, just a few years after the traditional white coat was banned in Scotland and largely phased out in England because of fears that it can spread infection. In some hospitals, the new dress code could include a white coat—short sleeved to comply with the “bare below the elbow” policy.
The death of the white coat
Debate over the merits of the white coat has been running since the 1800s (box) and did not go away when it was phased out in the UK in 2007. Writing recently on bmj.com, Andrew Burd called on doctors to “Rise up: re-take the initiative and elegantly and proudly re-drape the white coat around your shoulders.” He suggests doctors in the UK buy their own coats. “Get at least three,” he says. “Wear them with pride, and get back to work.”
History of the white coat
Doctors adopted the white coat in the mid-19th century to restore credibility to a profession that had been damaged by scientists, who had proved that many doctors’ remedies were worthless. Looking to associate themselves with science, doctors adopted the lab coat as a sign that they could be trusted to provide cures that were effective and backed up by the latest empirical thinking. Although lab coats were originally beige, doctors decided to choose white because it represented purity, holiness, and cleanliness. Hospitals were becoming places of healing rather than places that people went to die, and the white coat symbolised this.
Proponents believe that the garment has been maligned: the real reason the coats became unhygienic was the loss of hospital laundry facilities rather than any intrinsic issue with the coats themselves. Others remain unconvinced of any link between white coats and infection, demanding robust evidence for such an association. Some regard the abolition of white coats as a management plot to blur the distinction between doctors and other healthcare workers.
Burd cites a 1991 paper that asked doctors why they wore white coats. The most common reason given was to ensure that doctors could be recognised by colleagues and staff, but number four on the list was to emphasise “doctor status.” The 10th reason was to create “a psychological barrier.”
It’s this psychological barrier they erect between doctor and patient that has been cited as another argument for their abolition. Even when they were common among the wider medical profession, white coats were often eschewed by psychiatrists and paediatricians, who felt that they interfered with the rapport they needed to build for a successful therapeutic relationship.
Back in fashion
York Hospitals NHS Foundation Trust is the latest hospital to trial uniforms for medics. In a statement, a spokesperson said that the trust “intends to introduce uniform for junior doctors within the next 12 months and is currently conducting a pilot study to determine the best form this should take. In addition, a number of consultants have been trialling uniform for several months, although there are no immediate plans to implement consultant uniform more widely.”
The spokesperson added, “About 70% of our staff already wear uniforms, and the decision to provide them to junior doctors is a small extension of this well established practice. There is a real enthusiasm for this from many of our doctors, and, while recognising that the process for its introduction may be demanding, we feel this is a tremendous opportunity both to improve patient care directly and to make doctors more recognisable and professional in appearance to patients and their carers.”
The trust refused to comment further on what form the uniform would take and what the cost to doctors would be. But one incoming junior doctor at the trust has been told it would consist of “either scrubs or a white coat with shortened sleeves, in essence a normal white coat with the sleeves lopped off.”
The doctor criticised the lack of clarity over who would be responsible for laundering and who would pay for irreparable damage to the clothing. “Does it mean that if it gets grubby it’s our fault; if it gets blood stains all over it it’s our fault?” he asked. “That’s what it suggests to me. I don’t think that’s right.” He conceded there could be an upside, however: “It means I don’t have to bother ironing my shirt before work each day.”
Dress code already in place
Some hospitals have already implemented a mandatory dress code for doctors, albeit without the bespoke white coat. The first trust to introduce a uniform was West Middlesex, which since 2007 has enforced a matching short sleeved tunic and trousers in dark blue. The tunic has the trust logo and the word “Doctor” on the front, and a silver pinstripe for its “antibacterial properties” (figure ). The uniform is mandatory for junior grades; a version for consultants is available, but is not compulsory.
A spokesperson said that the uniform had been implemented “to encourage compliance with our ‘bare below the elbow’ policy, for infection prevention and control reasons, and also to present a professional image to patients and the public.
“Initially this meant a culture change for doctors, who had been used to not wearing uniforms. However, this has become accepted over the past few years. Patients like the professional image of the uniform, and they are able to identify the role of the doctors easily. Doctors give a refundable deposit for the uniforms, but do not have to purchase them. They are responsible for laundering it, as are all staff.”
The uniform has apparently been a roaring success. “It has improved the professional image, and our compliance with bare below the elbow has improved dramatically, from approximately 70% in 2006 to 95% and over,” said the spokesperson. “We were commended by the CQC [Care Quality Commission], when they visited the hospital in September 2009, for our higher rate of compliance with bare below the elbow—above most other trusts. Our infection rates for MRSA [meticillin resistant Staphylococcus aureus] and Clostridium difficile have decreased over the past few years and we feel that the uniform has had a part to play in this, alongside many other measures.”
Support from the Junior Doctors Committee
The move towards uniforms has been cautiously welcomed by doctors’ groups. Shreelata Datta, chair of the BMA’s Junior Doctors Committee, said, “We fully support measures that have been shown to be effective in the fight against infection. As such, we have no problem with NHS staff being asked to wear uniforms where the evidence is robust and clear on its benefit. However, we would expect all healthcare staff to abide by the same rules. It is essential that changing facilities, safe storage, and clothing of the correct size is available and in place prior to uniforms being implemented.”
Dr Datta was critical, however, of making doctors pay a deposit and launder the uniform at home. “This is unlikely to be a popular move and will be difficult to justify to debt laden junior doctors, many of whom would be happy to wear their own clothes to work.
“It would be far better to ensure that hospital property is laundered by the hospital, in the same way as hospital linen is managed by the hospital. Doctors should not be forced to incur costs on a condition that has been imposed on them without choice.”
Competing interests: None declared.
Oliver Ellis editor, Student BMJ