Dr. Philip Lederer harbors warm memories of the day he received his first white coat, in a moving ceremony to mark the start of medical school. A decade later, he has banished the garment and is working to persuade other doctors to hang up theirs, too.
The reason? The white jacket, he believes, is a germ magnet, one that can carry deadly infections from one patient to another.
The crisp white coat has long been worn to symbolize a profession — and purity. But some studies show the coats are teeming with microbes picked up in patient rooms.
Lederer, an infectious disease fellow at Harvard Medical School, wears a shirt, sleeves rolled up, convinced such attire is less likely than a coat to drag across the patient and spread infections. A few others where he works also favor the short-sleeve style.
“There is no harm in avoiding white coats,” he wrote in an online newsletter, “but there could be danger in wearing one.”
Many other doctors have no intention of abandoning the jackets. They question whether scrubs or street clothes — or bare arms, for that matter — are any cleaner, and worry the focus on attire will distract from proven safety measures, such as hand-washing.
The debate — largely good-natured — has assumed an intensity that surprises even its participants, exposing divisions that go beyond microbiology and touch on shifting perceptions of the physician's role. Those who call white coats dirty also find them elitist, a barrier between doctor and patient. Those who treasure the traditional garb believe it engenders trust.
When Dr. Paul E. Sax, clinical director of the infectious diseases division at Brigham and Women's Hospital, summarized the arguments in a blog earlier this month, the post got thousands of hits. The post had a survey question, and nearly 1,300 responded. The vote was almost evenly split: 49 percent say keep the coat; 51 percent favor getting rid of it.
"It has a lot of cultural significance," said Sax, who wears a white coat about half the time, and believes there's not enough evidence to give it up.
White coats have been a fixture in medicine since only the late 19th century. Doctors previously wore black, but switched to white laboratory attire to signal that medicine was science.
In 2008, Britain's National Health Service required doctors to go "bare below the elbows," to prevent spreading infections.
That got Dr. Michael B. Edmond thinking. Edmond, who was then the chief of infectious diseases at Virginia Commonwealth University School of Medicine in Richmond, believed the Brits had good reason for concern.
Lab coats are infrequently laundered. A survey of 183 physicians and medical students at Edmond's Virginia hospital found only 1 percent wash the coat every day, 2 percent every other day, 39 percent once a week, and 40 percent once a month. Shockingly, 17 percent said they had never washed their coats.
Edmond and Lederer both acknowledge the missing link: No study has shown that white coats transfer germs or increase hospital-acquired infections.
But it's logical to believe they can, Edmond said. Given the risk, he argued, who needs this attire? Edmond started wearing scrubs to work. In 2009, his hospital instituted a voluntary policy encouraging staff members to dress down, with no sleeves or coat. Gradually, as leaders such as Edmond modeled the new style, more physicians adopted it.
To address concerns about being cold and needing pockets, the hospital provides neoprene vests. Last year, a hospital survey showed 69 percent of staffers worked bare below the elbows. By this year, that had risen to 80 percent — a clear culture shift.
The Virginia hospital is apparently alone in adopting a hospitalwide policy encouraging "bare below the elbows." Edmond plans to institute the same policy next year in his current workplace, the University of Iowa Hospital & Clinics.
Lederer estimates that roughly 20 percent of his colleagues at the Brigham and at Massachusetts General Hospital work bare below the elbows.
Dr. Michael S. Calderwood, a Brigham infectious disease specialist, is keeping his white coat. Studies that measured the bacterial contamination on white coats compared with other clothing did not find a difference, he said. Meanwhile, at least six studies show patients prefer professional attire, and some found the white coat inspired confidence and willingness to share information.
Edmond countered: "If you're nice to your patients, if you communicate well, you're empathetic, you give them access to you, they don't care how you're dressed." As with everything in this debate, there's a countervailing study, saying patients don't miss the white coat when doctors explain why they've removed it.
Those who favor keeping the white coat point to guidelines developed by the Society for Healthcare Epidemiology of America, which concluded that the role of clothing in transmission of microorganisms remains unclear.
Still, the lead author of the guidelines, Dr. Gonzalo Bearman, who took Edmond's place at Virginia Commonwealth, works in scrubs and a vest.
"If you have an intervention based on biological plausibility, that is really cheap to do, that is almost certainly unlikely to cause harm," Bearman said, "we feel that's sufficient to go ahead and try."
It's unknown if the new dress codes lower infection rates. Hospitals everywhere have taken a variety of measures to prevent infections, and rates are going down. No one can tease out whether "bare below the elbows" contributed.
Dr. Neil Fishman, associate chief medical officer at the University of Pennsylvania Health System, debated Edmond in a forum at a recent conference.
Health care professionals, Fishman said in an interview, already have many evidence-based patient safety measures to carry out: preventing falls and pressure ulcers, becoming more diligent about hand-washing. Why distract from these critical tasks, he asked, by fretting about apparel?
"I'm just left scratching my head, trying to figure out why some really bright people who I respect have latched onto this issue," Fishman said.
Felice J. Freyer can be reached at firstname.lastname@example.org.