Our campaign to have clinicians voluntarily take off our white coats and roll up our sleeves started with concern about health-care associated infections (HAIs). HAIs are a leading cause of illness and death in the United States and worldwide. In 2011, an estimated 721,800 HAIs occurred in the US, leading to 75,000 deaths. Antibiotics have been a critical tool since the discovery of penicillin in the 1920s, saving the lives of millions of people around the world. Today, however, the emergence of drug resistance is reversing the miracles of the past eighty years, with drug choices for the treatment of many bacterial infections becoming increasingly limited. Meanwhile, reducing transmission of multidrug-resistant organisms and Clostridium difficile in hospitals is a critical priority. Infections caused by these pathogens are common and are frequently associated with adverse outcomes.

The relative role of clothing (white coats, ties, etc) in transmission of HAIs has long been a topic of controversy. However, what's indisputable is that white coats are coated with pathogenic bacteria and have the potential to transmit infections to patients. This discussion got ramped up in July 2015 with Vineet Chopra and Sanjay Saint’s article on The Conversation.  After they published their article, Mike Edmond and Eli Perencevich responded quickly on their blog. In September, Philip Lederer published an article on The Conversation, “It’s time for doctors to hang up the white coats for good.”  Subsequently, there was a debate between Mike Edmond and Neil Fishman at ID Week which received media attention and there has been ongoing discussion on Stopinfections.org, Philip Lederer's blog, Paul Sax's blog, and on social media. The mainstream media is beginning to pick up this issue and will continue to write stories about it, if we get organized. 

A few additional points:

• White coats are a powerful symbol, no doubt about it.
• We have much respect for the history/traditions of medicine, but we believe in engaging with the complexities rather than blindly accepting white coats as a hallmark of professionalism.
• White coats are popular among some (but certainly not all) doctors and patients. They vary by institution, geographic location, etc. 
• Their use been encouraged by the Arnold P. Gold Foundation’s White Coat Ceremonies.
• First-year medical students don’t really have the option to not participate in their school's white coat ceremony.
• If a medical student declined to put on a white coat in front of one’s peers in a white coat ceremony, that would be seen as socially unacceptable.
• We believe the Arnold P. Gold Foundation should stop including white coats as a part of its welcoming ritual.
• More and more medical students are reporting that their superiors have attempted to influence their dress during their clinical rotations.
• For example, some attendings make it clear that they expect shirts, ties and white coats for "professionalism."
• Students who disobey and take off the white coats and go "bare below the elbows" face the disapproval of their superiors. This should not be the case. 
• Patients don’t have a choice if their doctor is wearing a white coat or not. It would be almost impossible for a patient to tell his/her doctor to take off the white coat and tie and re-wash their hands.
• Physicians traditionally dominate in the doctor-patient interaction.
• We don't pretend that taking off white coats is a simple issue. Race, gender, and age are issues that need to be addressed. 

As you can see, the discussion about white coats goes well beyond the bacteria crawling all over their fabric. Many clinicians feel disempowered and burned out. And many patients are frustrated about health care costs and quality. Communication is often lacking in the health care encounter and the relationship between doctors, nurses, and patients is beginning to fray. 

A few more points to ponder:

• As the Right Care movement has pointed out, modern medicine offers important benefits yet it also has the capacity to cause harm
• Americans spend $2.9 trillion annually on health care and much of that is waste
• Despite the Affordable Care Act (Obamacare), many people lack access to high quality, affordable health care
• Clinicians are often relegated to the role of clicking off check-boxes on an electronic medical record (EMRs) and have very limited time with patients
• Poorly designed EMRs have lead to backlash- long hours in front of the computer, scribes, and most recently, a new ZdoggMD song on Youtube. "We need a new chart," ZdoggMD sings. 
• Insurance companies, drug companies, hospitals, and government bureaucrats control the health care system, not clinicians and patients
• Much of health care seems to revolve around the "business of medicine," aka billing
• Quality of care is often inconsistent, as the media frequently reports, making hard-working students and clinicians feel discouraged.  
• Care is quite frequently not patient centered because clinicians are so busy and rushed

Enough is enough.

We clinicians can voluntarily take off our white coats, roll up our sleeves, organize and mobilize. Like Rosie the Riveter during World War II, we can each take steps to improve quality and safety.

Take a few minutes and think back to why you went into health care in the first place. Quoting the RightCare Movement: 

"A more just and compassionate world where health and health care are basic rights. Where patients are safe from unnecessary diagnosis, treatment, and harm. Where patients' wishes are respected by their caregivers. Where clinicians serve as healers, and as advocates for those who are most vulnerable and in need of care, and where health care exists for the benefit of patients, communities and nations."

Along with signing this petition and voluntarily taking off our white coats, even busy doctors and nurses can commit to the following 3 actions:

1) I will clean my hands at every opportunity. I will also wash my stethoscope and limit the number of fomites (watches, ties, cell phones, etc, that I bring in proximity to the patient). I will not prescribe unnecessary antibiotics. Primum non nocere. First, do no harm.

2) I will provide patient-centered health care, despite the time constraints that I face in my busy clinical practice. Try to take the time to find a chair and sit down next to your patient and avoid looking at the Electronic Medical Record/ computer screen. Health care should be an equal partnership between clinicians and patients, and listening/ mindfulness goes a long way. 

3) I will "think beyond the exam room" and begin to work in my community. Is it possible to take a couple of hours and do a home visit for your patient who is particularly vulnerable? Consider joining progressive organizations such as:

• The Lown Institute (Join the "RightCare Movement")
• The National Physician's Alliance
• Physicans for a National Health Plan
• Society of General Internal Medicine
• Costs of Care
• The Society for Healthcare Epidemiology

Those of us who have taken off our white coats are not saying we are any "better" than clinicians who are still wearing them. Doctors and nurses wearing white coats are good, educated people and are not causing bad clinical outcomes. We are simply worried about possible harm from coats (as well as hand hygiene, other foamites, excessive antibiotic use, etc), and think our plan is a reasonable way forward-- a middle ground.

If you agree that stopping HAIs, saving antibiotics, and delivering high quality health care to everyone should be our top priorities, please sign this petition, Tweet/ Instagram/ Facebook to #stopinfections and #safehospitals, share with family and friends, and please join us in this work. Thank you.

best regards, 

Philip Lederer

cc: Eli Perencevich, Mike Edmond, Tim Lahey, Anthony Cannella