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.

  • Andrew Burd

    Just for clarification i should point out that the picture in the link to surgeons news has been cropped but there is a more extended view in the hard copy version that shows this very interesting pipetting technique.

  • DH

    Agree Andrew – Here is some evidence –
    Bare below the… What do patients want their doctor to wear?
    Authors: Henderson, J.; Budd, H.; Wimhurst, J.
    Source: Bulletin of The Royal College of Surgeons of England, Volume 91, Number 7, July 2009 , pp. 246-248(3)
    Publisher: The Royal College of Surgeons of England

    Bare below the elbows – difficile times for a health secretary
    Authors: Magee, T.R.; Dehn, Tom
    Source: Bulletin of The Royal College of Surgeons of England, Volume 90, Number 4, April 2008 , pp. 126-128(3)
    Publisher: The Royal College of Surgeons of England

  • S.

    delighted to hear you wash your hands inbetween pts and wash your coat. But, you will find infefeciton control audits have evidence of others not doing either. Sorry, i actually agree in principal, but, also know some of these coats do not see a washing machine in years

  • Pam Cushing

    Andrew I completely agree and while there is the infection control chestnut this has come about because of the devolvement and loss of hospital based laundries which affects the nurses as well as the doctors in terms of clean uniforms. It is time the doctors rose up against the “management” and became the leaders in medicine they were even 15 years ago. Get your teeth and professionalism back.

  • Keith Slater

    Your points are eloquently made and entirely correct. So many of the pointless initiatives and directives we now suffer at the hands of management result from edicts without a grain of evidence to support them. In our cash-strapped unit, we have just been instructed to completely replace all chairs, wall coverings and flooring, because of infection risk. We haven't had a single demonstrable ward-acquired infection in 10 years. Meanwhile the “vacancy monitoring committee” (an apt description if ever there was one) fails to replace the 3 nursing posts that have been vacant for 2 years now on the grounds of cost. Hong Kong sounds attractive.

  • Andrew Burd

    Many thanks for your comment and it is truse that there are/were filthy white coats worn by doctors who should have known otherwise…but I think it is partly a matter of professionalism and self-respect. Also i do wonder how many people wash their trousers and skirts/dresses on a regular basis?! And all that 'perineal fallout!' With regard to the coat washing I have to say that it was edited out of the blog but in HK we do have domestic helpers who do the washing…so I cannot claim the credit for myself.

  • carolynthomas

    Dr. Burd – you may wash your hands between patients and take care not to get blood, vomit, pus or any form of bacteria and virus on your lovely white coat while moving all day from patient to patient, but do you then toss your white coat into the laundry between each patient? Of course you don’t. Hospitals are by definition hotbeds of infection. I’ve worked in hospitals for the past decade and have seen how “clean” these so-called professionals and their white coats are.

    A white coat does not make doctors “leaders in medicine”. My own cardiologist wears flashy Hawaiian print shirts and long hair in a neat pony-tail and is by far the most professional physician I know.

  • Felix Freshwater MD

    We have taken the opposite tack here in the States. We have something called a “White Coat Ceremony” in which first year medical students are inducted into the professon by being given their 1st white coats

  • Andrew Burd

    My dear would you have your doctor go naked?! Of course not…so we have to wear something…but we are talking about a profession and not individuals. I am not sure what type of hospital you work in but it should not be a 'hot-bed' of infection. I do believe such a term should more correctly be used to describe the dish of free peanuts on the bar of your average English pub.

    But your point is well taken..a white coat worn by a dispirited and beaten group of professional's does not make them leaders in medicine. It takes a little more than that…but personally I do not think flashy Hawaiian print shirts and long hair, albeit in a neat pony-tail would do the trick either…not in the NHS at least. But I may be wrong!

  • Andrew Burd

    Felix, a wonderful link. I must admit that my first white coat at Aberdeen (my alma mater) was to protect my clothes whilst dissecting on the “drain”. This was vast hall that reeked of formalin and contained the cadavers that we spent 800 hours, yes, 800 hours dissecting. One body for each group of four students. Bizzarely those coats were absolutely disgusting to see and smell but most probably were infection free!

  • My dear Dr. Burd, you might be interested in this exchange of letters to the editor of our daily newspaper on precisely this issue.

    In the first letter, a heart patient demands: “Whatever happened to the white coat?” after encountering my Hawaiian shirt/pony-tailed cardiologist in hospital – whom she described as “the devil himself” because of his appearance!

    The second, my response, points out that my own life had been saved by this very doctor in the same hospital thanks to his knowledge of what I later learned was a rarely performed hepatojugular reflux diagnostic test before correctly identifying my “significant heart disease” and rushing me upstairs to the O.R.

    But I had been previously sent home from that same Emergency Department in mid-heart attack by an older doc wearing a lovely starched white coat after he misdiagnosed me with GERD, despite presenting with textbook heart attack symptoms (including pain radiating down my left arm – who knew this was a symptom of indigestion?!)

    I'd take the flashy Hawaiian shirt and pony-tail (along with that up-to-date medical expertise) compared to incompetence masquerading in a white coat anyday.

    Here's the link:

  • Fred Kavalier

    A few years ago the medical director of Guy's and St Thomas' sent out a directive that traditional white coats were to be banned, because of the risk of cross infection. He recommended that staff wear clean cotton garments, made of tightly woven material, regularly washed and pressed. A consultant colleague responded to say that the only garment in his wardrobe that matched this description was ….his white coat.

  • pete

    Everyone seems to miss the point that infection rates are generally much higher in Britain than in countries, certainly continental European countries, where white garments are de rigeur. In British hospitals, generally grubby in macroscopic terms too, doctors do ward rounds in their day clothes, approaching and nudging each bedside in turn in trousers which, lets be honest, do they really wash more than once a month? And this, amazingly, is seen as an advance. The reason this retrograde change came about? Yes, white coats WERE fomites, because lazy clinicians didn't change them daily or more frequently. In Continental hospitals, and doubtless elsewhere in the world too, the procedure is that all clinical staff arrive in their day clothes, enter the changing room, get into cleanly laundered whites (not as stuffy over-garments but as basic dress) and go about their daily patient care. At the end of the day the process is reversed and the 'whites' go straight into the laundry bin. One simply never sees the filthy spectre of nurses in uniform doing their shopping in Tesco's.
    Why wasn't this universal regime introduced in Britain at the time when MRSA & coliform problems were at crisis levels 5-10 yrs ago? Because managers knew that it would cost money to install proper changing rooms at all hospital staff entrances and to launder the uniforms of thousands of clinical workers. And the medical profession supinely accepted the nonsense article, written I seem to recall by students, suggesting that white coats were the cause of all the problems.

  • Adam Magos

    You are totally correct in your interpretation of why white coats were really banned in the UK – yet further emasculation of the medical profession (main reason) and cost cutting (lesser reason). Using infection risk was nothing more than a cheap ploy (just like “Bare below the elbows” was a cheap soundbite) by the government to deceive the general public as there is absolutely no evidence that white coats which are changed every day (as they should be and used to be provided by hospitals) are responsible for cross infection. Even the government document which heralded the “Bare below the elbows” policy admitted as much (Quote: “It seems unlikely that uniforms are a significant source of cross-infection”).

    I still miss not being able to wear my white coat, and feel sorry for my junior colleagues who have been forced to walk around the hospital with hand-bags. It's crazy. As much as I would love to take up your call to “re-drape the white coat around our shoulders”, it would not be tolerated. Sad, but true. Instead, I have taken to wearing a bow-tie, not because I consider this to be less of an infection risk than an ordinary tie, but because I hope it helps patients identify who is caring for them.

    I would, however, much rather wear the white coat I worked seven long years for. My hope is that if doctors shout loud enough, the new coalition government will have the sense to see the error of their predecessors and reverse this nonsensical, politically driven policy.

  • Wongsy

    Dear Heart Sister,

    I would prefer instead my doctor to be both an authentic up-to-date medical expert as well as one properly dressed up in a professional sense. Why should we drop one for another? The two are entirely independant and there is no logic why you have to compromise in Great Britain while the Commonwealth little brothers and sisters don't!

  • Named08

    Dear Professor Burd,

    I am a junior doctor from Brazil working in the UK. I have to confess that I was shocked with the fact that we could not wear white coats, not only because of that but also because of the explanation given: infection control. According to one of the doctors, the hospital can provide just one white coat per doctor so it cannot be washed every day. I asked then “why don't you buy your own white coat here in England?” “During my medical school I had different ones, tailored, short sleeve, long sleeve, for summer, for whiter, etc. While one is in the washing machine, the other is drying and the other is with me.” The doctor walked away. I totally agree with you in everything you have said above. It is power, it is respect, but above all it is hygiene (for those who wash their hands, their clothes…). I want to know if there is any research proving that the banned white coat changed the risen of infection in hospitals across the country. I could not find any yet. Is there any ballot (for doctors and patients) to bring the white coat back? I vote yes! Bring the white coat back!

  • Named08

    Just two questions: Do doctors, nurses and other health professionals wash their own clothes between each patient? Where is it easier to see a blood stain, in the white coat or in a black pair of trousers?

  • As a layman i.e. only medical knowledge is that from being at the end of a doctor's stethescope, I mourn the demise of the white coat. To me the white coat immediately told me who I was to yell for when wanting medical attention. It also did command my respect. How taking away a white coat can mean less infection I am not entirely sure. Are the clothes they wear now somehow super protected? Okay so you are not to wear white coats. Can you not sneak in an off white coat and wear that?