Archives of Medical Research 53 (2022) 533–534 OPINION The White Coat: An Outdated Tradition Marian E. Phinder-Puente,a Saúl Rayo-Rodríguez,a Héctor David Meza-Comparán,b Javier Mancilla-Galindo,c Ashuin Kammar-García,b,d Ernesto Deloya-Tomas,a and Orlando R. Pérez-Nietoa a Unidad de Cuidados Intensivos, Hospital General San Juan del Río, Querétaro, México de Investigación, Instituto Nacional de Geriatría, Ciudad de México, México c Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México d Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México, México b Dirección Received for publication May 18, 2022; accepted June 14, 2022 (ARCMED-D-22-00600). In the nineteenth century, physicians did not use white coats regularly. Instead, they used a black suit very similar to a tuxedo, a garment which conveyed not only a sense of elegance, but also the subtle notion that seeking medical attention was a last resort preceding death. The use of the white coat was popularized by nurses until the beginning of the twentieth century (1). The White Coat as a Fomite The custom of wearing white coats was formally introduced in 1910 by Dr. George Armstrong, president of the Canadian Medical Association. The whiteness in coats became associated with cleanliness, purity, benevolence and peacefulness (2). Ever since, they have become a feature that distinguishes physicians from others. During the 1990s, white coats were identified as potential sources of nosocomial infections (3–6). Wong and colleagues examined cultures obtained from the white coats of 100 doctors and found that the cuffs and pockets of the coats were the most contaminated areas. Of note, Staphylococcus aureus was isolated from ∼25% of the coats examined (3). Similarly, Banu and colleagues isolated pathogenic microorganisms such as Staphylococcus aureus and Pseudomonas aeruginosa from the collar, pockets, and sides of the coats. Furthermore, when examining antimicrobial susceptibility patterns of the isolates, they found similarities with other nosocomial pathogens in their hospital, showing a potential link between conAddress reprint requests to: Dr. Héctor David Meza-Comparán, Dirección de Investigación, Instituto Nacional de Geriatría, Anillo Perif. 2767, San Jerónimo Lídice, La Magdalena Contreras, Ciudad de México 10200, México; E-mail: [email protected] taminated coats and these infections (5). The extent of microbial contamination goes far beyond the white coat since ties, stethoscopes, and other items worn by healthcare professionals may also be sources of infection (7). International Recommendations The use of the white coat has been banned in healthcare institutions of the United Kingdom since 2007 under the “bare below the elbows” (BBE) policy which aimed to reduce the incidence of nosocomial infections. The BBE policy considers the use of short-sleeved tops rather than white coats during patient care activity to be good practice. Additionally, jewelry may hinder effective hand hygiene (8). In 2009, the American Medical Association passed a resolution encouraging the adoption of guidelines to dress in ways that minimize the risk of nosocomial infections, although they ultimately recommended further research rather than eliminating the use of white coats or adopting a BBE-like policy (9). Even though the white coat is still a symbol of the medical profession, it is a well-known vehicle for the transmission of nosocomial pathogens (Figure 1). Therefore, its use should be revised, particularly in developing countries, where the white coat tends to be mandatory under the justification of “appearing professional”. There are three important dress code recommendations for healthcare professionals, aimed at preventing the occurrence of nosocomial infections (10): a) Wear uniforms with bare forearms, without white coats, ties, long sleeves, or accessories such as watches, bracelets, or rings. 0188-4409/$ - see front matter. Copyright © 2022 Instituto Mexicano del Seguro Social (IMSS). Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.arcmed.2022.06.002 Descargado para Anonymous User (n/a) en Pontifical Catholic University of Ecuador de ClinicalKey.es por Elsevier en agosto 18, 2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados. 534 Phinder-Puente et al. / Archives of Medical Research 53 (2022) 533–534 solo hay que ser médico, sino parecerlo”, which roughly translates into “you not only have to be a doctor, but also look like one”. Nonetheless, a physician’s proficiency has little to do with his or her attire. Conflicts of Interest None declared. Supplementary Materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.arcmed.2022. 06.002. References Figure 1. White coats belonging to resident physicians from a Level Two hospital in Mexico. Neck and sleeves are visibly dirty. b) Perform hand hygiene with water and soap or a disinfectant solution. Remember the Five Moments for Hand Hygiene proposed by the World Health Organization. c) Clean stethoscopes and any physical examination device after direct patient contact with alcohol-based wipes. We respectfully extend an invitation to physicians, government officials, and healthcare professionals in general to reconsider the use of the white coat in healthcare facilities. In Latin America, there is a popular expression “no 1. Hochberg MS. The Doctor’s White Coat–an Historical Perspective. AMA J Ethics 2007;9:310–314. 2. Aggarwal R. The withering shine of white coat. Ann Indian Acad Neurol 2012;15:63. 3. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ 1991;303:1602–1604. 4. Treakle AM, Thom KA, Furuno JP, et al. Bacterial contamination of health care workers’ white coats. Am J Infect Control 2009;37:101–105. 5. Banu A, Anand M, Nagi N. White coats as a vehicle for bacterial dissemination. J Clin Diagn Res 2012;6:1381–1384. 6. Du ZY, Zhang MX, Shi MH, et al. Bacterial contamination of medical uniforms: a cross-sectional study from Suzhou city. China. J Pak Med Assoc 2017;67:1740–1742. 7. Baptista-González HA, CA Zamorano-Jiménez. Estetoscopio, bata y corbata, y el riesgo de infecciones nosocomiales. Med Sur 2011;18:195–202. 8. Uniforms and workwear: guidance for NHS employers. 2020. Available from: https:// www.england.nhs.uk/ wp-content/ uploads/ 2020/ 04/Uniforms- and- Workwear- Guidance- 2- April- 2020.pdf (Accessed May 17, 2022). 9. Henderson J. The Endangered White Coat. Clin Infect Dis 2010;50:1073–1074. 10. Hernández-Orozco HG, Bearman G. Uso de uniforme con antebrazos descubiertos o bata blanca. Rev Lat Infect Pediatr 2017;30:133–135. Descargado para Anonymous User (n/a) en Pontifical Catholic University of Ecuador de ClinicalKey.es por Elsevier en agosto 18, 2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
