Curbside Consult with Dr. Jayne 5/16/22

With the rise of telehealth, there’s a lot of discussion about “web side manner” and the strategies that physicians and other clinicians should use when evaluating and treating patients via telehealth.

I’ve worked for a variety of telehealth employers, some which require their clinicians to wear a white coat and others who are fine with what they discuss as a “professional” dress code. For many years in the hospital culture, white coats were considered a symbol of being a physician or physician in training. Typically, medical students wore short coats and those with their degrees wore longer coats. However, over time, many other clinicians began to wear white coats both short and long, including pharmacists, nurse practitioners, physician assistants, and more.

The use of the white coat also evolved at the department level. At the hospital where I primarily trained, medical students wore short coats and residents, fellows, and attendings wore long coats. Except, that is, for the surgery department, where interns and first-year residents were further hazed by being required to continue to wear short coats.

However, the policy in the operating suites was that if you were wearing surgical scrubs and needed to leave the area, you were required to put on a long white coat or a “cover gown” to protect the surgical scrubs from non-OR contacts. However, the surgery interns knew they’d get in trouble if they were caught in long coats, so if they left the OR and there were no cover gowns available, they’d have to change back into street clothes and then don new scrubs when they returned. They detested the fact that students could wear the long coats in that situation, but they couldn’t.

The surgery interns were further hazed by being required to wear ties if male, and not being allowed to eat or drink anywhere but the hospital cafeteria or a break room. Where the rest of us could scurry away from the cafeteria holding a to-go cup and finish it in the elevator on the way back to our duty assignment, the surgical residents had to either chug it in the cafeteria or remove the straw to make it look like they weren’t drinking it until they got to their destination. There were a lot of other elements of hazing in those programs, and needless to say, they were a turn-off for a lot of students rotating on the service. This was also long before COVID, when masks changed how we handle food and drink in hospitals.

Since the white coat is no longer a definitive indicator, quite a few of the hospitals that I’ve worked at have taken to other methods to make sure patients know the credentials of different members of their care teams, including oversized name badge frames or backings that contain prominent credentials such as MD or DO or RN written in bold font that is nearly an inch tall. Still, there’s often confusion about who is caring for the patient, as noted in this recent Medscape article.

Despite all our advances in patient engagement and consent, the use of whiteboards, bedside technologies to track the care team, and more, patients are still confused about who they’re talking to. Some of that can have situational influences since hospitals are strange and unfamiliar places with routines that don’t often make sense. Patients may be less perceptive than usual due to illness or being overtired, since we know that hospitals aren’t great places to get rest.

Following the emergence of COVID-19, those bold credential nametags became even more necessary as many of us ditched white coats (which were largely used for their pockets anyway) in favor of scrubs that we could change before going home. Neckties all but disappeared as we tried to understand the nature of this novel pathogen. Other countries had previously moved away from white coats and neckties due to the infection risk, but the US has been a holdout. When I spent some time in a healthcare institution in the UK many years ago, no one wore sleeves of any kind below mid-forearm to allow for better hand hygiene, and neckties had also been voted off the healthcare island.

Still, there’s the question of how clinicians should dress for telehealth visits. The reality is that our world has become much more casual since the start of the pandemic. Plus, there’s no need for those white coat pockets when you’re sitting at a desk and can use a laptop, PC, or phone to access references rather than having to tote around a “Washington Manual” and a “Pocket Pharmacopeia.” However, there’s still that association of the white coat with professionalism.

The article cites research done at Johns Hopkins to look at patient preferences. Nearly 500 adults were surveyed in the spring of 2020. They were asked about various types of dress, including white coats, scrubs, and fleece or softshell jackets with the institution’s logo. They were also asked to rank photos of models in various attire to identify their level of experience, professionalism, and friendliness. Those models in white coats were seen as experienced and professional, while those in softshell jackets were seen as friendlier. Responses varied by age of those surveyed as well as their geographical location. The white coat seemed to be favored by older respondents as a mark of professionalism.

Another study conducted at NYU Grossman School of Medicine in 2018 surveyed over 4,000 patients at 10 academic medical centers. Those patients preferred formal dress and a white coat, but it would be interesting to see what a study of that size would show in the pandemic-era and whether the results would hold across different encounter settings including inpatient, outpatient, and telehealth visits. At least for the majority of patients receiving telehealth services, they’re not being seen by a whole team of people, so I would hypothesize that the white coat is not necessarily helpful to avoid confusion on what type of provider is present.

Personally, I prefer not to wear the white coat while conducting telehealth visits. I wore it only intermittently in my solo practice, mostly because I had no need for the pockets and everyone knew I was the doctor. In the emergency department, I wore it for the pockets, but ditched it when I went to urgent care. I did bring it back for COVID, partly because my employer couldn’t provide adequate gowns and it was one more layer of protection, not to mention I didn’t want a stethoscope around my neck given our initial lack of understanding about COVID transmission – pockets made much more sense.

Still, I wear it on certain telehealth visits when a particular employer requires it, even though I don’t like it and I don’t think the patients really care. It will be interesting to see how telehealth culture evolves over the next few years and whether the white coat becomes more or less of a requirement.

What does your institution think about white coats and telehealth? Leave a comment or email me.

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