Wearing your white coat – and perhaps your ego and patient’s bacteria – in public

White coat in public place edited

People can wear what they want in America. Whether you want to debut the latest vogue or your midriff rife with adiposity, you are free to do so. But just because you can, doesn’t mean you should. In the span of one week, I found two people – on two separate occasions – wearing white coats, each eliciting a different reaction from me.

In the past few months, I have made a conscientious choice to buy more of my groceries in the form of fruits and vegetables – and less in the form of boxes, cans, containers, and cartons, and you may want to do the same. Although Winn-Dixie does not sit at the pinnacle of grocer quality – like perhaps Whole Foods, it does offer a reasonable produce selection at a reasonable price. As I happened to be picking out nectarines, I glanced up and felt that I was hallucinating. In escaping the hospital, I found it inescapably in front of me: a man in his white coat. In one of those moments where you realize something is wrong but don’t know what, I thought maybe I had not seen him correctly – maybe he was a chef and was wearing a white apron? Or maybe I was still in the hospital and this was normal? Snapping to reality, I realized he was at Winn-Dixie, and I was too. He was wearing a white coat, but I was not. I took out my camera and snapped away.

My first reaction was: What the hell? This is gross. First, I don’t even leave the hospital without washing my hands. This guy brought 20 square feet of a microbiological zoo to buy fried chicken! Maybe he has a really good excuse. Maybe he got fired from the hospital (and couldn’t leave his white coat at the hospital), his car got stolen (so he couldn’t leave the white coat in the car), and was so busy talking on the cell phone that he didn’t realize he could disrobe and fold his white coat for placement in a shopping cart or basket. Maybe he also didn’t realize that he had committed a more heinous oversight: wearing sandals with his white coat – the coup de grâce. I was apoplectic that more people were not pausing their purchasing activities to gawk at this unfathomable fashion faux pas.

White coats are dirty. In one Israeli study, more than half of physician’s white coats harbored pathogenic bacteria, like Pseudomonas, Acinetobacter, Staphylococcus aureus, Enterobacter – even some with antibiotic resistance1. The concern over the transmission of disease had led Britain’s National Health Service to ban doctors wearing white coats in the hospital, and the United Arab Emirates’ Ministry of Health to ban it outside the hospital. Washing your white coat doesn’t help – unless if you’re washing it several times a day. According to one study, white coats worn just 8 hours after washing have as much contamination as one that is washed “infrequently” 2. Wearing your white coat for just 3 hours gets you to the 50% level of contamination.

No one has shown that doctors wearing white coats outside the hospital increases illness in the general public, but one study showed transfer of multidrug-resistant organism from cloth to pigskin was possible 3. In theory, transfer from cloth to human skin should also be possible. Whether that translates into morbidity and mortality remains to be seen, but why risk smearing methicillin-resistant Staphylococcus aureus (MRSA) on every surface in Winn-Dixie?

I myself have worn scrubs, albeit begrudgingly, outside of the hospital, but never a white-coat. Doctors, like everyone else, have lives to live and errands to perform. Sometimes, I’ve had to pick up dinner or go to the ATM on the way home. But, I don’t wear my white coat. I’ve never even thought of wearing it out of the hospital, let alone with sandals. To me, it is so unorthodox it rivals opening an umbrella indoors. When I do wear scrubs out, I sometimes take off my scrub top and wear my plain and completely unfashionable T-shirt to minimize any possible bacterial trail and, more importantly, to avoid signaling to the rest of America that I work in a hospital.

The second time it happened, I was again not prepared. I was driving home, listening to the BBC on the radio, when I had reached the tail of a line of cars waiting on a red light. As I waited, I listened to the latest headlines being rattled off. And then I saw it, less than a week’s passing from the first sighting. Again, I thought, It couldn’t be. But it was! A white coat on a person outside of the hospital! I stared at her and wondered, What the hell? Again, I snapped away (see above picture on the right). Not only are you wearing a white coat outside the hospital, but you are really wearing it outside! In the middle of summer, the heat and humidity in Miami is unbearable. Even if you forgot you were wearing a white coat as you sat in your car and turned on the air conditioner, you would definitely remember wearing it as you opened your car door and the sauna-like environs slapped your face. You would definitely remember you were wearing a white coat as your core temperature rose, your back started to sweat, and your thalamus went into overdrive to keep your body cool.

The only way a person would wear a white coat in such a setting is if they actively chose to do so. There is no excuse as she could have easily laid her white coat down in the back seat or trunk. The most logical explanation for a person to elect to wear a white coat in public is to signal that they are in the health care profession and, more specifically, are a doctor, whether they are or aren’t. White coats are associated with doctors as toque blanches are associated with chefs. One could easily wear a white coat in public to signal to others that they are not just any “Joe” or “Jane.” If being doctor confers special treatment in public, then one could use it for such a purpose. I don’t know if any such promotional sale or treatment by the major gas stations for physicians, but maybe I am wrong. Chefs don’t wear their hats in public. Neither do judges wear their robes in public. Imagine if they did – what a farce! Doctors, and anyone else possessing a white coat, should follow suit and refrain from using the white coat in a personal situation.

White coats are easily removable, unlike scrubs, which is what makes it a point of contention. Even though I consider scrubs being barely socially acceptable, many do not4. I am actually not even the first to post about someone wearing a white coat at the gas station. I found a medical student posting about another instance of the exact same situation5. In his/her blog, they write that perhaps this white-coat wearer was attempting to signal their perceived lofty status as a doctor. However, any attempt to do so backfires as it more blatantly reveals the “doctor’s” lack of awareness.

The use of the white coat for secondary gain is actually a violation of the medical professions’ ethos. Doctors are doctors to be doctors. The only time it might – barely – be appropriate to wear a white coat out is if one was making a house call. When I was a medical student, one of my family medicine attendings did make house calls – something of a rarity these days – and he didn’t even wear a white coat. I assume if you’re knocking at someone’s house, the tenants already know you are their doctor. Second, doctors are human – just like our patients. Wearing a white coat does not separate us from disease, emotion, or people. Although the white coat signifies our profession, it shouldn’t be used to distance ourselves from those around us – whether we are inside or outside the hospital.

But maybe all of these out-of-place doctors had valid reasons. I don’t know. I am curious to know what you think. Maybe if this keeps up, people will start saying, “You can take him out of the hospital, but you can’t take the hospital out of him.”

Or not.

References:

1 Wiener-Well, Yonit, et al. “Nursing and physician attire as possible source of nosocomial infections.” American journal of infection control 39.7 (2011): 555-559.

2 Burden, Marisha, et al. “Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8‐hour workday: A randomized controlled trial.” Journal of Hospital Medicine 6.4 (2011): 177-182.

3 Butler, D. L., et al. “Transmission of nosocomial pathogens by white coats: an in-vitro model.” Journal of Hospital Infection 75.2 (2010): 137-138.

4 http://www.physiciansweekly.com/scrubs-wearing-in-public/

5 https://medschooltrap.wordpress.com/2013/09/06/wearing-your-white-coat-in-public-is-not-cool/

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Finding fulfilment in an unexpected place: smoking cessation

In residency, they say the days are long and the years are short. Buried beneath the hours and work, it can be hard to find joy in the work we do. The work of a resident isn’t always filled with life-saving moments and wind-blown hair. In fact, moments where we personify our Grey’s Anatomy or House counterparts are scarce or implausible. Babies are not delivered pristinely clean and patients rarely walk out of a hospital after having had CPR. For internal medicine residents, our work of taking patient histories, performing physical exams, analyzing data and pinpointing the right treatment is less glorious and more repetitive. Given what we actually do, it is not surprising that 76% of internal medicine residents have experienced burnout at some point.

However, what we do is still important. We treat chronic heart disease, obesity, diabetes, high blood pressure, low blood pressure, and many other things in between that Hollywood never shows because the effects are more subtle, especially in the clinic setting. It was in one of these moments that I unexpectedly fell upon the sense of fulfillment. I had been in clinic, typing a visit note – my attention fixed on the computer in front of me – when my patient had started to talk about his smoking. My patient had smoked for decades and would be nearly breathless every time he arrived in my clinic room after calling his name in the waiting room. Smoking was part of his biker, jean-clad persona. I never had the time to lay out a few minutes to discuss all of the aspects of his smoking given all of his other medical problems but in previous visits I at least had covered the first two “A” of the five “A’s” of smoking cessation counseling: asking about smoking and advising to stop if they do smoke. In fact, nearly 80% of smokers don’t receive any further counseling during the average office visit.2,3 A woefully high number that has been attributed to simply the lack of time doctors have.4 In one study, the minimum amount of time for smoking cessation was determined to be three minutes – less than the amount of time to microwave a bag of popcorn. But when you add up the time needed for all the other things doctors have to do in a clinic visit – 190 other tasks (yes, people did count this and published it) – it adds up! 5 One study looked at the amount of time it would take to just cover prevention – all the things you should be doing to prevent a disease or its complications down the road, like getting enough, wearing a seat belt, being checked for sexually transmitted diseases, having a mammogram, et cetera. For one physician’s clinic patients, that physician would have to spend no less than 4.4 hours of each and every day just on the sole task of health care prevention! 5 Clearly, physician time is constrained and we are forced to make decisions on which area of a patient’s health care we should focus on. It is not an ideal situation, but this is one of several hard realities in health system with limited resources.

At the least, I try to see my patients more often to cover all those other things. Every time I did see this particular patient, I felt compelled to tell him to stop smoking. In studies, barely any intervention has been shown to be better than nothing at all. 6 If you don’t have time to spend the minimum three minutes, at least telling your patients that it is one of the worst things they could do for their health and they should stop is better than waiving the white flag and letting them walk out. In my limited attempts to have my patient stop smoking, I somehow managed to pull this off and it felt great.

“Doc, I have to tell you something,” he said.

“What is that?” I replied, barely listening while my face was buried in the computer screen looking up notes of his cardiac history.

“I took your advice and quit smoking.”

My response was nothing short of a contained tonic-clonic seizure. It was surreal. “Really?” I stammered from my mouth while my mind thought differently, “You listened to me? I was solely responsible for you giving up your twenty year habit of smoking that probably has given you heart disease, COPD, erectile dysfunction, and who knows what else? I struggle with basic life tasks like avoiding ketchup on my shirt and I somehow convinced a real live person to give up smoking!” I looked around the room half-expecting to find it was a prank, half-hoping to find somebody recording this life-changing moment – life-changing for him and for me – but found none. It was a quiet victory that deserved a loud celebration. For this person’s health, I single handedly had altered the course of his future health by getting him to quit smoking. In a parallel universe, I had avoided my patient perhaps going down the road of having heat attacks, being hospitalized for breathlessness, or succumbing to an early death. For example, quitting smoking can add a whole decade to one’s life expectancy. By not inhaling cigarette smoke, patients avoid exposure to the 70+ known carcinogens and thus reduce their risk of cancer. After several years, risks of cancer and heart disease can approach those of non-smokers. After his casual announcement, I stopped my note browsing and gave him the congratulations he deserved. On the inside, I felt like I had received my own reward: fulfillment as a doctor.

Finding fulfillment in smoking cessation is not easy because quitting smoking is not easy. On average, it takes a patient 8 to 11 attempts before they successfully quit smoking. 7 The longer a person goes without a cigarette, the greater the chance of successful cessation.8 Although smoking is not as common as it used to be, nearly 1 in 5 Americans smoke and nearly 1 in 5 deaths are attributed to it. 9 Kicking the habit is worth it for the patient. As a result, physicians should participate in some form of counselling with every patient at every visit. 10 In time, patients will quit. Resounding victories are rare in medicine, but when they do happen, they are a reminder of our purpose as physicians. And despite not being shown on TV, moments like this certainly are a bright spot in my day.

References:

  1. Shanafelt, Tait D., et al. “Burnout and self-reported patient care in an internal medicine residency program.” Annals of internal medicine5 (2002): 358-367.
  2. Ferketich, Amy K., Yosef Khan, and Mary Ellen Wewers. “Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS).” Preventive medicine6 (2006): 472-476.
  3. Thorndike, Anne N., Susan Regan, and Nancy A. Rigotti. “The treatment of smoking by US physicians during ambulatory visits: 1994-2003.” American journal of public health10 (2007): 1878.
  4. Yarnall, Kimberly SH, et al. “Primary care: is there enough time for prevention?.” American journal of public health4 (2003): 635-641.
  5. Wetterneck, Tosha B., et al. “Development of a primary care physician task list to evaluate clinic visit workflow.” BMJ quality & safety1 (2012): 47-53.
  6. Stead, Lindsay F., Gillian Bergson, and Tim Lancaster. “Physician advice for smoking cessation.” The Cochrane Library (2008).
  7. Women and smoking: A report of the Surgeon General. [US Public Health Services], Department of Health and Human Services, 2001.
  8. Hughes, John R., Josue Keely, and Shelly Naud. “Shape of the relapse curve and long‐term abstinence among untreated smokers.” Addiction1 (2004): 29-38.
  9. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
  10. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions