When I started practising 5 years ago, I thought "I don't need any stupid symbols, I'll practice in coat and tie, that should look professional enough".

What I have lately seen quite often (it may be either a US wide development or something that is more a local phenomenon) are disrespectful patients. These are patients that have an attitude that is hard to work with: late/noshows/same day cancellations, patients who argue about doing certain tests but have no idea what they are talking about (I very much respect a patient who has read up and have an informed question/request), patients who complain by telephone that symptoms didn't get better but who did not take their medications as instructed (even though they were instructed and even received written discharge instructions) etc.

This is a growing minority of patients. I think the above attitude has to do with the fact that patients usually don't foot the bill themselves, and that in my region, physician avilability is extraordinary - you usually can be seen here within a few days if not same day, including specialists.

And that's part of the reason why I go back to practising at a unversity group in a few months - patients are likely more respectful of university based doctors, and they have to wait a few weeks before they are seen for nonurgent problems (preventing senselesss doctor shopping that I observe here), and maybe I will even go back to wearing a white coat in the office.

We should draw a line between health care and wellness. Health care is not a consumer experience. The patient should expect a high degree of professionalism and dedication from the people working with him/her (and if that's not the case, changing docs/hospitals is entirely appropriate), but if one wants to be endulged, a spa is a better option.

traugott:

patients who complain by telephone that symptoms didn't get better but who did not take their medications as instructed (even though they were instructed and even received written discharge instructions) etc.

That's going to be a part of your entire career. If you can find a way from stopping patients from doing this, write a book on it and retire on the proceeds!

This is a growing minority of patients. I think the above attitude has to do with the fact that patients usually don't foot the bill themselves, and that in my region, physician avilability is extraordinary - you usually can be seen here within a few days if not same day, including specialists.

On the "disrespect" part, what do you think about *patient age* as being the cause? It seems to me like most people in their 70's + up are respectful in general, but now that the "60's people" are getting older and showing up with problems the "I want" attitude and disrespect for your labor has gone way up. Anyway, do you think the attitude change in your patients might be due to their generation?

You reflect the problem with doctors; you focus on your image. Apparently you were not paying attention during any infectious disease tour.

Despite the superman aura doctors emit, they are subject to diseases too. Supposedly the white coat prevents taking your work home with you or to lunch. However, most doctors are too aware of their image and refuse to give up their symbols. How does the idea of being the next one to sit at the same table that the doctor sat at during a SARS epidemic go over?

What should happen is that the white coat should be worn only while examining patients. It should be changed at least daily or when it is known to be around a contagious patient or sample. Street clothes should not be an option either since the doctor may be bringing germs in from outside the hospital which may be a problem for already sick patients or patients with comprimised or weakened immune systems.

This should also apply to medical professionals in scrubs as well.

at bondsman: I think it is in part a generational question, but not entirely. Moreover, patients who do have an obvious, potentially life saving problem tend to be more reasonable and cooperative (but that's not always the case).

Ranger, I was in fact only referring to the image- or better: cooperation- and respect problem. I would not advocate wearing the lab coat in the hospital (I mentioned the outpatient setting in my OP)... I am not aware about problems with (clean) street clothes with "regular" inpatients, maye you heard more. There are certainly well known exceptions such as immunodepressed patients, and patients with certain inf. diseases (e.g. TB, MRSA) that have regulated precautions. Frequent hand washing/desinfection is probably more important than wearing scrubs, from all what I hear from ID.

Like I said earlier, wash your coat.

It isn't just "image"! You can have the World's Best Treatment Plan, and if your patient doesn't follow it -- it's useless. Therefore, communication is very important, and the end result of that communication is to *get the patient to do what's good for them*.

Many people pay more attention to a professionally-dressed physician in a white coat than they do to a guy in a T-shirt, shorts, and sandles even if the two are saying the exact same thing (yes, I've seen a doctor dressed that casually). BTW, it's ALSO been my experience that these casually dressed docs are NOT doing so to prevent infection, but it fits better with their self-image or lifestyle. I can see the patients' POV, btw. I'd be a bit uneasy if I dressed up more to see my doctor than my doctor did to see me.

Unfortunately there are very few studies for the what is carried on street clothes. I am sure there are no doctors who pick up their cat and pet it right before going in to work. I am curious what the definition of "regular" is? Is that the knee replacement? Is it the geriatric with pneumonia? Aren't most people who are inpatients sick in some way meaning they are more subject to infection?

Urinary tract infections, skin and mucosal infections, infections of the surgery site and pneumonia are the most prevalent nosocomial diseases.

I am a professional microbiologist and am appalled at the usual hand washing practices by medical professionals. True NIC3 units and similar high sensitivity areas are good, but the routine handwashing by medical professionals does not follow what elementary schools teach; sing happy birthday through twice while washing hands.

http://www.cdc.gov/cleanhands/

I have seen nurses drop iv lines with open cannulas on the floor and try to use them (I stopped her).

I have seen techs lay injection needles on pads stained previously with blood (it was only a litlle spot).

Most medical professionals have nearly zero aseptic technique.

Ranger,

If you think MD's are bad, stick around a hospital and see how well the rooms are *disinfected* between patients given the current "budget first" attitude. I'd bet you'd cut down a LOT on nosocomial infections by truly cleaning rooms before they're put back into service again.

Remember, the staff is only part of the people in the hospital, and you can't stop the MRSA, HIV, or other + *relative* of a patient from visiting them, and touching everything and everyone in sight.

And with the I.V., etc. that's a cultural thing at that facility. If you had infection control demonstrate proper technique and say you'd *fire* any staff that didn't comply AND did NOT punish staff who threw away rather than use potentially contaminated lines (and the expensive drugs hanging from them), all that would change, IMO.

Visitors generally only visit one patient/room. Doctors and staff don't. Nor do most visitors perform procedures which put them in contact with infectious materials.

visitors touch buttons in the elevators, handrailings, nurses's desks, etc. that are common areas. It's bizarre that you are worried about a healthy doctor's coat infecting someone, but are NOT worried about an MRSA positive visitor as a source of infection, or someone who may be a TB carrier coughing all over the place.

Personally, I don't know any physicians that wear their white coats while performing invasive procedures -- if nothing else they are too restrictive. In at least the last 10 years at least I've never seen *anyone* start an IV or draw blood without wearing gloves. (although there was that guy on TV that stitched up the HIV + diver's head without wearing gloves)

A coat can only be a source of infection if it picks UP an infectious source and carries it somewhere else, right? If the potential places to pick up infectious sources is decreased, the chance of a doctor carrying one to someone else will decrease regardless of what they are wearing. And seriously, if you want an antiseptic environment, you need to be more like the operating room or an isolation room where a doctor puts on a NEW gown to see each patient. Even if you are the second patient of the day and your doctor is wearing tight-fitting scrubs, that's no proof that his first patient wasn't an ebola patient that sneezed all over him. But you're going to hit a cost/benefit wall pretty quickly if you want to force doctors, nurses, aids, etc. to put on a new gown between each and every patient they see.

You watch too much tv and have never worked a real emergency room. The epidemology studies tell us that visitors are not the source of most nosocomial diseases. It is poor practices of medical staff. Pushing a button on a MRSA tainted elevator (highly unlikely unless the previous finger has an open wound) does not give nosocomial type diseases.

I have seen too many doctor's areas where the white coat was hung up and used again. I have seen too many scrubs worn to and from work. I have seen too many street clothes worn to see patients; after the doctor picked up the family cat? Those are the real issues not the straw ones you create.

TheRanger:

You watch too much tv and have never worked a real emergency room. The epidemology studies tell us that visitors are not the source of most nosocomial diseases. It is poor practices of medical staff. Pushing a button on a MRSA tainted elevator (highly unlikely unless the previous finger has an open wound) does not give nosocomial type diseases.

I have seen too many doctor's areas where the white coat was hung up and used again. I have seen too many scrubs worn to and from work. I have seen too many street clothes worn to see patients; after the doctor picked up the family cat? Those are the real issues not the straw ones you create.

I thought I'd give you the benefit of the doubt and try and find an article or two showing how infectious a doctor's coat was. I read a half a dozen CDC articles on nosocomial infections, mostly they blamed cephalosporin or other antibiotic use for the rise, and some on *handwashing* or instrumentation.

None mentioned doctors' coats as being significant sources of infection. Cat petting either.

I did find this <link> on the bbc saying England might ban doctors' coats, but without any real evidence it will make a difference. I also tried googling for "nutter nosocomial doctor coat" and came up with this <link> which actually DID have evidence that *wearing short sleeves* cut infection risk in half. The trouble is the stated reason was this allowed for more efficient handwashing. Focusing on handwashing will likely reduce infection risk for anything, They really should have done a control group of people who were encouraged to wash their hands more in their coats. It's like saying engines last longer in a group of people who were forced to maintain there air pressure in their tires, while not mentioning that at the same time they were filling their tires they changed the oil in their car. It wasn't really filling the tires with air that made the engine last longer, changing the oil did. Just so, *washing their hands better* seems far more likely to cut infections than taking their coat off.

So far I haven't seen anything saying wearing a coat is a real health risk, but OTOH, improper handwashing and improper antibiotic use IS. I'm open to reading any articles you have that contradict the above, but for now have to attribute this to the "paranoia" bin.

You really are a simp. Let me help you out; you will probably never find an article about cat petting and nosocomial diseases. Toxoplasmosis (a protozoan), psittacosis (virus) and ringworm (fungus) are only examples of zoonoses from pets and other animals.

You don't understand the culture of aseptic technique. Since scrubs and white coats are already available, use them effectively. Change them at least daily; not monthly. Don't wear street clothes in the hospital. How often do doctors clean their business suits. If the wear shirt and tie, how often do they get their ties clean.

It is a culture (pardon the pun) of awareness from the janitor to the hospital administrator.

<link>

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CDC has recognized this fact. As an elementary school student I am sure you were told how important hand washing is, but if you think that is the panacea of infection control you are sadly mistaken. Even handwashing is at best casually done by most doctors. Even floor exam gloves are useless if the doctor puts them on and then touches fomites. Infection control is a culture of awareness. Unfortuately a lot of doctors only worry about protecting themselves.

Your suggested experiment might be good when you reach 7th grade, but how about culturing jackets and ties and see what grows like sab with chloramphenicol. Ring worm is so nasty when you are lying in bed.

You are still focused on the white coat as a symbol. You don't need a white coat to be professional. Shorts and sandals I admit detract.

The idiocy of focusing on the white coat is clearly demonstrated at the drug store where some clerk who is being "supervised" by the real pharmacist is actually filling your prescription wearing the infamous white coat. And if you think the pharmacist is paying close attention, dream on especially at Walmart.