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Friday, July 11, 2014

Dressing well and keeping our white coats until the evidence tells us otherwise

The problem of health care-associated infections (HAIs) and the morbidity that they cause is gaining more media attention with each passing week. The numbers are mind-boggling: according to the Centers for Disease Control and Prevention (CDC) over 700,000 HAIs occur nationwide in acute care hospitals, affecting almost 5% of all hospitalized patients1. In addition to the costs in human suffering, there’s also the financial burden, estimated at $10 billion a year for the 5 most common infections2; ventilator-associated pneumonia, surgical site infections, catheter-associated urinary tract infections. Clostridium difficile colitis, and central line-associated bloodstream infections.

It’s also understandable (and expected) that as the scale of this problem becomes more publicized, and Centers for Medicare and Medicaid Services (CMS) is increasingly tying reimbursements to hospital infection rates, health care organizations everywhere are ramping up efforts to lower their numbers. Being the most visible frontline specialty, the role of hospital medicine doctors is absolutely crucial in leading the fight.

All of us who practice at the frontlines will be familiar with the common day-to-day infection control methods employed on the floors, such as gloves and gowns for patients with vancomycin-resistant enterocci, or droplet precautions for patients with influenza. But more needs to be done, and many other novel ideas are being put forward. There have been calls for special lights on badges that turn green when hands are washed, videotaping all doctors and nurses, everyone wearing newly cleaned scrubs every day, and even encouraging patients to regularly ask their doctors if they’ve washed their hands. A further approach that’s being proposed and increasingly talked about is a strict “bare below the elbows” rule for all health care professionals. This would completely change the way doctors dress by banning white coats, long sleeves and any watches or jewelry. For the males, ties would also be banned.

It’s a strategy that’s already been used overseas. In 2007 the United Kingdom’s National Health Service (NHS) banned all doctors in the country from wearing long sleeves and ties. I left the NHS to start my residency here in America a couple of years before that. Not that the medical world is ever a fashion contest, but the United Kingdom probably went overnight from having some of the best-dressed and professionally attired doctors in the world to having them arriving to work in short sleeves and open collars. No white coats to be seen (however, slightly different over there, because it was typically only medical students who used to wear white coats anyway). The measure was a drastic change and one that was met with a fair degree of skepticism. Is there actually any evidence that long sleeves and ties spread infection?

A look at the available scientific evidence tells us that although some studies have shown that clothing can potentially become contaminated with bacteria3, there have as yet been no studies that have demonstrated a direct causation or shown that restrictive dress codes make any difference at all to infection rates. One such study from New York that specifically looked at neckties and found that they could carry pathogens4, got some attention in the news media, but did not establish any causality. It’s entirely plausible that the same results may have been found if doctors’ other garments were swabbed. Indeed, a larger study in the Journal of Hospital Medicine found that there was no difference in MRSA contamination of physicians’ white coats with that of newly laundered, short-sleeved uniforms after an 8-hour workday. After just 3 hours, the cleaned uniforms already had 50 percent of the colony counts that they did at 8 hours. Furthermore, contamination of the skin at the wrists of physicians wearing either type of clothing was the same5.

And despite the ban in the NHS being in place for 7 years, recent government data from the UK suggests that hospital infection rates remain stubbornly high. Statistics show that 1 in 16 people treated at a hospital contract an infection, what the National Institute for Health and Clinical Excellence called “unacceptably high.”

Could a “bare below the elbows” scenario become mandated here? In 2011 the New York State Senate proposed that exact policy (without the support of the state’s Medical Society). It hasn’t become law yet. More recently, the Society for Healthcare Epidemiology also suggested the same approach6. At the other end of the spectrum, the American Medical Association said in 2010 that there was “little evidence linking clothing to infection rates” and called for further research before adopting restrictive dress codes. Of course, over here we don’t have a single authority that can overnight impose such severe measures on doctors and hospitals. The same goes for having a handful of politicians with excessive power (who usually have no health care or scientific qualifications) who may be eager to get the headlines as “infection fighters”, such as happens in many countries with centralized systems.

Without any compelling evidence, banning all white coats, long sleeves and ties may thus be a step too far. There’s also another big downside to doing this: patients actually quite like their doctors dressing professionally (as do customers in any arena). In one study, 400 patients were shown pictures of a doctor in various outfits; including professional-looking with a white coat, scrubs and sneakers, and jeans with a t-shirt. The results showed that overwhelmingly patients preferred their doctor to be dressed professionally with a shirt and white coat7. The same went for female physicians too, minus of course the tie. The authors concluded that wearing professional dress could favorably influence trust and confidence-building in the medical encounter.

So if not changing the way we dress, what can hospital doctors do on a daily basis that really works? Plenty. There are lots of evidence-based techniques on how we can lead the charge against hospital infections, many of which we are already doing. For instance, washing hands thoroughly with soap and water for at least 30 seconds8 in between patients. This is probably more likely to help stop infections than anything else. Regular use of alcohol scrub is effective against most organisms (although doubts exist for its effect on C. difficile). Gloves, gowns, and bleaching rooms are other common sense measures. If we’re talking specifically about preventing C. difficile, one of the most feared HAIs, another article in the Journal of Hospital Medicine concluded that the cornerstones are; contact precautions, strict hand hygiene, environmental cleaning and antibiotic stewardship9. Allied with sensible advice such as regularly laundering your clothes, disinfecting stethoscopes in between patients and ensuring your tie doesn’t “hang down” over patients, we can all take small but powerful steps whenever we are on the floors. Keep in mind too that scientific progress may soon render this debate obsolete anyway, as antimicrobial sprays and other infection-combating inventions arrive at the frontlines.

The most rational way to proceed for now would be to carefully weigh all the evidence, look for local trends, and act accordingly. Which hospitals have low infection rates and what are they doing right? Let’s learn from those that are already ahead of the curve while we wait for more quality studies to come out.

I must confess, I like dressing up professionally to go to work. Patients sometimes compliment me on my shirt and tie, and when I put on my seasonal ties around the Holidays, it frequently brings a smile to my patients’ faces! But rest assured, the minute high-quality controlled studies show that white coats and ties cause infection, I’ll be the first to advocate removing them. The challenge of science in general is to establish causality, and to avoid mass hysteria. While we undoubtedly have a lot of work to do in lowering hospital infection rates, we should avoid knee-jerk unproven reactions.

Hippocrates, who seems to have had so many words of wisdom for the medical profession from more than 2 millennia ago, had a clear idea in his mind of what a doctor should look like. This included three pieces of advice on being: “clean in person, well dressed, and anointed with sweet-smelling unguents”. We should be sure before ditching the second one.

References
1. Magill SS et al. Multistate Point-Prevalence Survey of Health Care-Associated Infections. N Engl J Med 2014;370:1198-208.
2. Zimlichman E et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46
3. Wiener-Well Y et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011 Sep;39(7):555-9.
4. American Society For Microbiology. “Doctor’s Neckties: A Reservoir For Bacteria?” 104th General Meeting of the American Society for Microbiology 
May 23-27, 2004, New Orleans, Louisiana
5. Burden M 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. J Hosp Med. 2011 Apr;6(4):177-82.
6. Bearman G et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014 Feb;35(2):107-21
7. Rehman SU et al. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov;118(11):1279-86.
8. Noskin GA et al. Recovery of vancomycin-resistant enterococci on fingertips and environmental surfaces. Infect Control Hosp Epidemiol. 1995 Oct;16(10):577-81.
9. Dubberke E. Strategies for prevention of Clostridium difficile infection. J Hosp Med. 2012 Mar;7 Suppl 3:S14-7.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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