The white coat: Symbol of respect, or a liability?

A doctor's white coat is not only a staple of healthcare attire, but it’s also a symbol of professionalism, authority, kindness, and trust. While medical students know that trust is earned through practice, donning the white coat marks an important milestone in their journey to doctorhood.

But the glory of this esteemed garment may dwindle when one considers the harm it could cause. Not only do white coats serve as vehicles for pathogens, but they also shine a light on patients’ perceptions of gender and professionalism, revealing gender bias in some cases

What the white coat carries

In addition to the hopes that they evoke, white coats are responsible for high? rates of horizontal transmission of bacteria in hospitals. 

In one study published by the Canadian Journal of Infectious Diseases and Medical Microbiology, 12 nurses working in six separate wards wore two 10 cm x 15 cm white coat fabric patches on their sterilized uniforms during shifts. At the end of day, the nurses submitted their uniforms to be analyzed for bacterial pathogens.

Pathogens like Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Acinetobacter spp, Bacillus spp, Micrococcus spp, and coagulase-negative staphylococci (CoNS) contaminated half of the white coat fabric swatches. 

Contamination more than doubled between the first and second workdays, causing the colony growth per square inch of the patch to jump from 524 CFU/inch2 to 857 CFU/inch2.

Swatches from nurses working in maternity showed the highest levels of contamination, while swatches from nurses in the surgery ward showed the least contamination.

The results of this study confirm that white coat fabric can carry pathogens. This can increase the risk of transmission to patients, potentially contributing to healthcare-acquired infections (HAIs).

A review published in the American Journal of Infection Control echoes these findings. The study found that white coats and surgical scrubs often transport multidrug resistant organisms (MDROs). Some HAIs could be attributed to provider attire that transmits MDROs.

Despite this, doctors may still wear white coats because of what they represent to themselves and to their patients.

Perceptions of professionalism

Since the 19th century, white coats have served as a symbol of cleanliness and achievement. Today, they are also largely associated with a physician’s credibility and status. According to a survey published by JAMA Network Open, most patients prefer doctors to wear formal physician attire as opposed to casual wear.

The Institutional Review Board of Johns Hopkins University spearheaded the analysis of the survey, which asked participants to use a 5-point Likert scale to measure where and how often they saw physicians wearing white coats, scrubs, fleeces, and softshell jackets. The respondents then ranked the importance of friendliness, experience, and professionalism among doctors. Finally, participants measured those qualities in photographs of doctors in various attire.

The results reinforced the perceived superiority of white coats across the board: Fleeces and softshell jackets earned an average rating of 3.1 for denoting experience, while white coats skated at 4.9. 

For professionalism, white coats earned another 4.9 rating, compared with a 3.3 for softshell jackets and 3.2 for fleece. 

Softshells were rated 3.1 on average for friendliness, while white coats received an average of 3.6.

Each physician’s position also played a role in the significance of their attire. For example, respondents preferred surgeons to wear white coats over scrubs. Family physicians and dermatologists, however, were preferred to wear business innerwear under a white coat.

Gender bias and physician attire

Another dimension of the JAMA survey captured the influence of gender on perceived professionalism among doctors. 

Compared with pictures of male models wearing white coats or scrubs, pictures of female models wearing identical attire evoked lower ratings of professionalism from participants. 

Even when female and male models both sported white coats in photos, male models were more commonly identified as physicians. Female models were often perceived to be physician assistants or technicians.

When wearing scrubs, female models were likely to be perceived as nurses, while male models were perceived as surgeons. Overall, female models were reportedly less professional-looking than male models in all sections of the survey.

Even with the pervasiveness of projected gender biases coupled with pathogenic transmission risks, the white coat is still a meaningful article for many doctors. 

Tonya Fancher, MD, MPH, an associate dean for workforce innovation and community engagement at the University of California, Davis, School of Medicine told the AMA, “I do think it carries that real symbolism of being in the field. When someone in the hospital sees someone with a white coat, it indicates that [they] are someone who knows what’s going on, and that’s just kind of the power of the symbol.”

Sources

1. CDC. Strategies for Optimizing the Supply of Isolation Gowns. Centers for Disease Control and Prevention. 2021.

2. Goyal S, et al. Bacterial contamination of medical providers’ white coats and surgical scrubs: A systematic review. American Journal of Infection Control. 2019;47(8):994-1001.

3. Mishra SK, et al. Bacteria on medical professionals’ white coats in a university hospital. Canadian Journal of Infectious Diseases and Medical Microbiology. 2020;2020:e5957284.

4. Murphy, B. The meaning behind your white coat. American Medical Association. 2020.

5. Xun H, et al. Public Perceptions of Physician Attire and Professionalism in the US. JAMA Network Open. 2021;4(7):e2117779.