Walk into a hospital in the United Kingdom, Ireland, the Netherlands and much of Scandanavia and take a good look around. What don’t you see? No male physicians wear ties. No one is wearing a lab coat. No one — male or female — is wearing rings, not even a lone wedding band. No watches adorn wrists – people pull them out of their pockets when they want to check vital signs. No stethoscopes dangle around the neck of either doctors or nurses. There is instead a stethoscope in each patient’s room.
Now consider the United States or Canada. White coats remain the symbol of status for physicians and some elite nurses, like nurse practitioners. Women and men wear rings galore, and it’s hard to find anyone without a wrist watch. Ties — mostly traditional long ones — are de rigeur for docs. And stethoscopes are draped casually around the neck as if the latest fashion accessory.
Why the difference in medical equipment and attire? Health systems in the UK and Europe have acted on studies that document the fact that pieces of standard medical equipment and attire pose the risk of harboring and transmitting a host of dangerous organisms to patients. Ties can dangle into wounds as a doctor is examining a patient; it isn’t therefore surprising that ties have been shown to be colonized with hospital superbugs. Rings can shelter untold dangerous organisms underneath the band, inside an intricate setting, or even in the tiny spaces etched out by a loving inscription. It is impossible to keep many germ free, even if medical staff members take off their rings and washed them everytime they cleaned their hands. Watches and bracelets carry the same infection control hazards. As for stethoscopes, it should come as no surprise that these can be laden with lethal organisms yet are rarely cleaned between patients.
As for lab coats, their long sleeves are constantly touching patients and transporting germs from one to another. They are never changed or washed between patients and rarely laundered everyday, as are hospital scrubs. With scrubs, which leave the arm below the elbow bare, it’s much easier to clean the entire arm that might have inadvertently brushed a patient, a bedsheet, or an open wound.
While numerous studies have documented these dangers, many in healthcare will argue that with the exception of artificial nails, there is no smoking gun that directly links pathogens on a ring, tie, watch etc. with a bad patient outcome. In a culture that worships randomized controlled trials, lack of such “grade A” evidence allows the system to maintain the status quo until further research comes along. One can only imagine how long it will take to run study where patients are rubbed with a contaminated tie or lab coat versus a placebo…
That’s why the Europeans have acted on available evidence rather than wait for the impossible to happen. For them, removing such obvious sources of possible contamination is just common sense much like wearing a helmet while snowboarding. In the United States and Canada, despite more than a decade of intense concern about patient safety and the increasing number of hospital borne infections and “superbugs” there has been little serious action taken on the tie/ring/lab coat etc front. In fact, many prominent patient safety advocates seem to dismiss these things with a kind of “what can we do about it?” shrug. Inactivity speaks volumes: are we really serious about these issues or are people more wedded to the trappings of status and power, or fashion, which not only provide infection risks to patients but also perpetuate the kind of silos and hierarchies that are rife in modern medicine and that are also risks to patient safety. On a recent trip to Sweden where doctors wore short sleeve scrubs and had forgone jewelry, they looked and acted like they were part of the team. Doing away with these medical accessories costs little or nothing. Plus it may help health professionals act their way into a new way of thinking about patient safety.
Suzanne Gordon’s latest book is “Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork.” Dr. Michael Gardam is medical director of Infection Prevention and Control at University Health Network and Women’s College Hospital in Toronto.