Should Doctors Go Bare? Infection Control Debate Rages

Hospital-acquired infections and the rise of drug-resistant organisms has put new focus on whether requiring doctors to go “bare below the elbows” (BBE) would help infection control. BBE means no long sleeves, no neckties, no wristwatches, no jewelry other than a wedding band, and generally that physicians will wear scrubs.

The practice was adopted in the UK in 2008. But it appears to be a tough sell in the US. At a debate today at IDWeek 2015 in San Diego, two physicians squared off in a friendly—and highly entertaining—debate.

Michael Edmond, MD, MPH, MP,of the University of Iowa Hospitals and Clinics said his hospital is going BBE January 1, 2016. He took the “yes” side of the debate. Neil Fishman, MD, of Penn Medicine in Philadelphia, PA, took the “no” side and closed his debate with a hip-hop style rap.

Edmond began by citing studies that showed how dirty and microbe-contaminated lab coats could get. Though some surveys have shown patients prefer to see their doctors in coats and ties, “Patients preferences vary” and the survey techniques may bias the answers, he said.

Edmond said he was convinced that BBE would help infection control since staph and other organisms persist on clothing, lasting over a month on white coats, particularly if they are polyester not cotton.

One survey showed the iconic white coats are laundered infrequently, with about half the physicians in one survey saying they washed them once a month. “Quite appallingly, 20% said they had never washed them,” Edmond said.

Though there have not yet been any random controlled studies showing that patients treated by physicians wearing white coats and ties had higher rates of preventable infections that those treated by BBE physicians the concept “has biologic plausibility,” Edmond said. Further, trying BBE has “no risk, except to some people’s egos” and minimal cost.

Nonsense said Fishman. “There is no evidence that BBE works,” he said. With all the headaches and challenges physicians and hospital face “You want us to be fashion police too?” Fishman presented a slide show that featured hairy forearms, tattooed forearms, and arms of men with plaque psoriasis, suggesting that baring forearms could be unprofessional and even hazardous.

And what about the “commit to sit” doctrine that encourages physicians to talk to patients at eye level, not tower above them. “Will going bare below the knee be next?” he asked. Edmond, showing photo of a filthy white coat he said belonged to a coworker, said it was simply common sense to think BBE would be safer and cleaner. “Your mother would tell you that,” Edmond said.

Fishman responded with quotes from a UK physician who charged that the BBE practice of wearing scrubs had led to a “less robust view of infection control” in which physicians began to neglect hand-washing and acquired “a slovenly personal appearance.” Other complaints were that doctors never knew what time it was and had "no place to put their stuff," he said.

In a straw poll after the debate, the audience sided 58% to 42% with Fishman, who at one point showed a slide of himself in a white coat, his arm around the shoulders of a life-sized cutout of Pope Francis, a recent visitor to Philadelphia. The pontiff was wearing white vestments, Fishman pointed out.

Ending the debate on a more serious note, Edmond challenged Fishman to compare his hospital’s infection data with Edmond’s after the Iowa hospital ho has started its BBE policy. He is confident there will be fewer hospital-aquired infections, he said.

Editor's note: An earlier version of this story misstated Dr. Edmond's institutional affiliation.