Andrew Burd: Bring back the white coat

Andrew BurdHelen, a delightful medical student from the University of Aberdeen in Scotland, has been staying with us for an elective.  All overseas students are asked to provide their own white coats and our visitor from the UK told us that she had to borrow a white coat from a Hong Kong friend.  There are no more medical white coats in the NHS.  This was a passing comment on the morning rounds but it certainly stimulated a lot of discussion.  I have just forked out a relatively hefty sum to buy a fitted white coat with designation, name, and specialty carefully embroidered above the pen pocket, as have several other team members. We like our white coats in Hong Kong. We wear them with pride and many buy their own and wash them. So what is the problem with white coats in the UK? 

I tracked down an article in the Journal of the Royal Society of Medicine on, “Why do hospital doctors wear white coats?” According to the article it is primarily for status. The second most popular reason was to have pockets to put things in. But by the turn of the century the NHS was changing, rapidly and drastically. I got out just in time. I cannot imagine what it must feel like to be told by a business manager, which cases to operate on and have some other group dictating how the operation should be done. And then have yet more people taking away junior staff mid-procedure because they have run over time.  

The BMJ ran a piece in 2004 that caught my eye. A senior registrar in general practice predicted the death of the white coat on the grounds of elitism, as the white coat no longer held the respect it once did. The BBC also reported on the dying of the white coat and caught the mood of doctors and patients.  It was rather drawn out and this reflected the ongoing war between the medical profession and the management.  The managers wanted to disempower doctors and to do that they had to attack their status.  And this was done insidiously with government led targets.  Targets that were all to do with politics and very little to do with the practice of medicine.  Perhaps there is an element of wishful thinking in this but I witnessed the plummeting of morale amongst surgical colleagues in the NHS in the later half of the last decade.

So when the white coat died in 2007, what was the reason? Infection. The BBC and Associated Press both reported that doctors in the NHS will no longer wear white coats. They are an infection risk. What absolute nonsense. White coats do not cause infections. It is the sloppy, careless, dirty, demoralized people who wear them that cause infections. I wear a white coat; wash my hands between patients; and wear a mask, gown, and gloves when dressing a wound. It is a clean white coat. But in the UK, I have a sneaking feeling, that this was the final battle in the war between the medical profession and the management. It smacks of collusion for both sides to agree that the white coat should go for the same reason. A reason which is so startlingly insincere.

No, it was the final blow in the emasculation of the NHS doctors. The public sector doctors had lost their status. “Everyone” wore white coats; even mortuary attendants.  So the “status” of the white coat changed.  It was no longer associated with leadership.  And so, ashamed, the medical profession grabbed at what little face saving they could whilst getting out of the white coat. And so the fiction of “infection” was born.

But what greater event happened in the world at the end of the last decade?  The destruction and devastation by a virulent infection of greed in the high world of international finance.  This is not abstract.  It really happened and now the coalition government have had to introduce unprecedented austerity measures to bring the UK back from the brink of bankruptcy.

I read the Economist and in the issue of 17th July 2010 there was an article entitled “Once More into the Ring.” It was about Andrew Lansley trying once more to reform the NHS. Give power back to the GPs and cut management costs by 45%.  How many management jobs can be eliminated before there is any observable deterioration in service?

But let us forget about the managers. What about the medical profession?  This must be viewed as a great opportunity.

Rise up: re-take the initiative and elegantly and proudly redrape the white coat around your shoulders.  Look at the picture that goes with the article in the Economist.  A tired and stressed middle aged man looking not unlike a French President.  A stethoscope hangs round his neck but it does not look authentic.  The model is wearing a purple shirt and a striped dark tie, but horror of horrors, he is wearing cufflinks.  What a fate, what a fraud, and what a pathetic portrait of a doctor. 

This is the public image of the medical profession, or at least the image of the picture editor of the Economist.  Doctors in the UK; buy your own white coats; get at least three.  Wear them with pride and get back to work.  Next issue to push into the past; EWTD.

There is a short postscript.  Look at Sn Global August 2010 ( on p.21 there is an article entitled “Focussed on Research;” a report from a fifth year medical student at the University of Aberdeen, Ms Helen Gillespie.  And there is a picture of Helen, our visiting elective student to illustrate the article.  She is demonstrating the complex, single hand, double pipette technique, whilst she wears a gleaming white coat. Actually, she isn’t. Demonstrating the single, hand double pipette technique. It is just a trick of the angles that makes it look as if she is holding two pipettes, but she is wearing a white coat.  What does that mean?  White coats; good enough for scientists but not good enough for doctors, or is it the other way around?

Andrew Burd is professor of plastic, reconstructive and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.