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Doctors sound off -- loudly -- about wearing scrubs on the street

Doctors sound off -- loudly -- about wearing scrubs on the street

william heisel, health journalism, scrubs
Dr. David C. Martin may be onto something.

In three Antidote posts last week, he made the case that health care workers should not wear surgical scrubs out in public and that, if they are seen doing so, they should be confronted.

"Only after it is proven that scrubs in public cannot spread disease to others can we legitimately support the practice," he wrote.

His three-part piece, which ran Monday, Wednesday and Friday, generated a massive number of emails and tweets from physicians and other medical professionals. Many of them fell into Martin's camp. In the absence of evidence to the contrary, they wrote, why risk spreading dangerous pathogens such as MRSA by wearing scrubs to and from a hospital and dropping the deadly beasties on buses, in restaurants and at day cares along the way?

A few said that Martin was proposing a draconian solution to a relatively minor problem and that, should the health care field start clamping down on scrubs, they might as well prevent health care workers from carrying cell phones, laptops and all kinds of other objects that can ferry pathogens from the hospital to the home and everywhere in between.

And a few, including Skeptical Scalpel blogger Dr. James Barone, a Connecticut surgeon specializing in acute care and a fellow writer here at Reporting On Health, told me that, if nothing else, scrubs in public just look wrong.

"We have a tremendous image problem in the medical industry anyway," Barone told me. "Because of the perceived prevalence of medical errors, people are amazed that anyone can get through the ordeal of being in the hospital. So just for the sake of improving our image, we should probably leave the scrubs at home."

He elaborated on his thoughts in a post of his own last week.

Here's more of the best of what people had to say about the issue. I intend to explore some of these ideas more fully in future posts.

"I think it's primarily a matter of hubris, that doctors think they're above the rules. Add to that a tired/overworked effect. Doctors are hungry and stressed, so they go "grab" a sandwich without taking the time to go change first." – Medical Lessons blogger Dr. Elaine Schattner, a New York oncologist, clinical associate professor of medicine at Weill Cornell Medical College and new ReportingonHealth member.

"While I understand the concern of the anaesthetist, is he also mounting a campaign against pens, iPhones, pagers and stethoscopes, as all have been shown to harbour awful bacteria as well? That's not to say he's wrong, and perhaps we should in fact be mounting just such a campaign. Sometimes it's difficult to weigh utility vs. best practices. Certainly best practices would involve the removal or cleaning of all of those fomites before public exposure. Of course if we did, could there be potential harm in an MD not having a tool available for an urgent call, or could he or she be delayed while changing back? Were I mounting a campaign, it would likely still be for hand washing, as sadly, despite painfully clear cut risk, many don't wash as often or for as long as required. Given most people wash/recycle their scrubs daily, but likely never wipe down their smartphones, pens and scopes, I'd be willing to wager that the scrubs are the lesser evil of that bunch." - Dr. Yoni Freedhoff, founder and director of the Bariatric Medicine Institute  in Ottawa and creator of the Weighty Matters blog. (Antidote interviewed Freedhoff in March.)

"I personally think it is a bit overboard. Twenty percent of people can carry resistant bacteria. Will we scan them and forbid from public places too?"Dr. Howard J. Luks, associate professor of orthopedic surgery at New York Medical College, and chief of sports medicine and arthroscopy at University Orthopedics and Westchester Medical Center. (Translated from Twitterese.)

"With rare exceptions, such as unusual pathogens that survive as spores, microscopic organisms die quickly on dry surfaces. This is the basis for a common sign in hospitals that says, "If it's wet, wear gloves." By the time a doctor or nurse walks out of a hospital, I suspect that his or her scrubs are dry and no living organisms could be cultured from the fabric. In contrast, the person sitting next to you in a plane may be a reservoir of dangerous germs. His or her moist nose may be full of dangerous bacteria. He or she may cough up all sorts of nasty germs. That moist wad of Kleenex would probably culture out some interesting microbes.  I also suspect that your main risk of infection in a restaurant is the person who sneezes or coughs while preparing your food, not the doctors sitting at another table with dry scrubs. The real risk of wearing scrubs outside a hospital may be the opposite of what this article implies."- Dr. Bruce Flamm, professor of obstetrics and gynecology at the University of California, Irvine, and health writer. (Antidote interviewed Flamm in November 2009.)

"A small change could make a bigger impact than we realize."Dr. Harry Greenspun, chief medical officer at Dell Services healthcare group and a member of the World Economic Forum's Global Health Advisory Board.

"Given the choice between focusing on hand hygiene, an issue that has very clear data documenting transmission of infectious agents, and scrubs outside the hospital, a practice that has not been shown to be involved in disease transmission, most organizations would focus on the hands. Extending the argument about scrubs just a bit, you could argue that scrubs should not be worn in the public corridors of the hospital, in the gift shop or in the cafeteria. All are frequented by members of the public. Personally, I agree that the practice of wearing scrubs to and from the hospital and in the public is a bit untidy and perhaps elitist. Soiled scrubs are just wrong where ever they are worn. But I would say the same thing about a butcher wearing his or her soiled apron in public. I am reminded of an experience I had several years ago while fishing in Vermont. We stopped for lunch at a diner and were just served when a native came in from the dairy farm. We knew where he worked even before we turned. It was obvious that he had been in the barn from the smell and his clothing. As I read the piece, I had the image of that farmer in Vermont. He, like the physician and nurse, did not think about the image they were portraying and in the impact on others. While distasteful, arguing that scrubs are a public health menace is a bit of a stretch." – Harold DeMonaco, director of the Innovation Support Center at the Massachusetts General Hospital and one of the medical editors at Health News Review.

"In the 1980's when I did residency in NY, it was absolutely forbidden at my hospital (the Hospital for Joint Diseases Orthopaedic Institute) to be seen out of the OR in scrubs. You were to change in and out of and then back in again if you had to leave temporarily. It would be under threat of dismissal from the program if you ever saw a patient in anything but a white coat and tie. (I was once reprimanded for not having a tie on for a Saturday medical lecture by the Chief of the hospital, who gave me the key to his office to go get a tie immediately.) Yet outside the hospital, residents who would sneak out their scrubs and wear off hours usually did it to attract women by letting them know they were doctors .Fast forward to the present. Doctors, nurses, along with all sorts of ancillary medical providers like physical, respiratory and occupational therapists will wear scrubs all day long and then leave the hospital. I have little doubt that being around sick ICU patients with all sorts of infections can leave those bugs on the scrubs. Unless you're in the OR and change into new scrubs before you leave, then I would agree that the possibility of bringing hospital acquired bacteria and viruses to outside environs occurs." – Dr. Charles Rosen, clinical professor of orthopaedic surgery at the University of California, Irvine, founding director of the UCI Spine Center, School of Medicine, and president of the Association for Medical Ethics. (Antidote interviewed Rosen for one of our very first posts.)

Perhaps one of the best comments was from a fascinating little company called Patho Phizz. The company wrote, "Our scrubs already come with superbugs."

That's right. They make scrubs that are made of patterns of pictures of pathogens like E. coli, botulism and candida. The company sells them as fashion statements, not as part of a public health campaign, but think of the possibilities?

If Patho Phizz can make MRSA-patterned scrubs (and perhaps write MRSA in big football-style letters across the back) maybe health care workers would be less likely to wear them outside the hospital.

If you have thoughts on what should be done (if anything) about scrubs in public, send me a note at askantidote [at] gmail [dot] com or respond in the comments below.

Comments

Thanks so much for this thoughtful, and tangible series that seems to have hit a nerve with quite a few. I should clarify that in recent years I've spent more time as a patient than as a practicing physician. That said, from my patient's perspective these articles are terrific, and needed -

The author replies:

First and foremost, I am pleased to witness the copious and highly varied responses that my piece has generated, some quite passionate.  As I said, “dialogue is almost always a signpost on the road to quality improvement.”  One of my goals is simply to get this issue under the microscope.  Let me offer a few comments in response to some of the more common, contrary threads among your replies.

 

Some posts have belittled the scrub issue because there is no direct proof that wearing contaminated scrubs in public can be established as the proximate cause of superbug infection in the community.  Anticipating this sentiment from a few readers, I stated, “the use of hospital-exposed scrubs in public has never been proven as the direct cause of a single infection.”  Clearly, this is not the type of study that can be done, ethically or practically- recall the Tuskegee Syphilis Study as an extreme example- which is why caution, along with inferential decision making is necessary.   Since we cannot subject a study population to superbugs under the controlled conditions necessary to “prove” a connection, we are forced to create policy based on common sense. 

 

In so doing, it helps to look at what has been proven.  Superbug infections, some fatal, are on the rise among people in the community who have not entered hospitals.  (See http://www.biomedcentral.com/1741-7015/6/2 for example).  And hospital scrubs taken from hospital worksites are frequently colonized with these organisms, though one physician’s comment incorrectly suggests otherwise.  Does it really require complete proof to connect these dots?  There are surely other fomites to blame, but clothing does cover a substantial portion of our bodies, and changing clothes takes mere seconds.  We are not talking about cumbersome “hazmat” suits; we are discussing changing in and out of what amount to a pair of pajamas.  Is that really a draconian measure?

 

Furthermore, we are also addressing what has become policy at many institutions, yet some respondents have trivialized the need for compliance.  This lack of respect for decisions that are made consensually by the greater medical community and the very institutions that make our practices possible is unprofessional and irresponsible.  And as one respondent opined, this in itself undermines the respect of those who depend on us for healthcare services.

 

Other respondents have cited other examples of potentially controllable superbug fomites, suggesting that lack of their control is reason to trivialize the scrub concern.  Instead, why not address these other concerns as well.  Neckties, as one post mentioned, have been addressed elsewhere as inappropriate, and should not be worn in the hospital.  In fact, many support a “nothing below the elbow” dress code, which also makes sense.  White hospital gowns, aka labcoats have been amply proven to be filthy and infrequently washed.  In my last place of practice, dozens of them hung on common coat racks, in physical contact with one another.  These garments, often used to cover up scrubs, are probably worse than scrubs, many going months or years between cleanings.  Yes, shoes are another concern.  A pair of shoes should be devoted exclusively to the hospital, and remain there at the end of each day; this is common practice among my surgical and anesthesia colleagues. 

 

Can we sterilize ourselves before and after our daily commute or eliminate the transmission of infection among ourselves?  Of course not, but why do nothing because we cannot do everything. Yet some respondents have trivialized my concern because it is incomplete and imperfect.  Healthcare workers that direct their efforts toward what can be provided perfectly will have short workdays.  Again, let us respect what we don’t fully understand.  For those few among you who demand proof, why not respect the wellbeing of others by insisting on that same level of certainty to support your contrary position?

 

-David C. Martin, M.D.

 

 

I find it interesting that the medical profession has no concern about wearing scrubs outside the hospital. Sitting the other day on dirty seats in an auto oil change store I noticed a couple of nurses in scrubs also waiting for an oil change to their car. Having worked in the food industry (industrial) for many years we were not allowed to wear our "whites" when leaving the building. This was in accordance with FDA rules regarding food manufacture. I some bakery food plants you are even required to change into different shoes/boots before entering the processing facility. Hard to understand why the medical profession is so much more lax that the food processing industry.

I find it interesting that the medical profession has no concern about wearing scrubs outside the hospital. Sitting the other day on dirty seats in an auto oil change store I noticed a couple of nurses in scrubs also waiting for an oil change to their car. Having worked in the food industry (industrial) for many years we were not allowed to wear our "whites" when leaving the building. This was in accordance with FDA rules regarding food manufacture. I some bakery food plants you are even required to change into different shoes/boots before entering the processing facility. Hard to understand why the medical profession is so much more lax that the food processing industry.

Very interesting. My concern though is the opposite. I'd be more worried about a medical professional sitting on a filthy subway seat then treating patients in the same scrubs. I'd be more concerned about what he or she will pick up from the bus or subway rather than what they'll leave behind.

I have never seen a nurse or doctor overseas wearing scrubs after work.

I saw a nurse in Phoenix, AZ, who lived in an apartment next door, was taking her garbage out and touched the dumpster with her hands and clothes while throwing her garbage bag away.

So, my question is: how much bacteria she got on her clothes?

And another question, if you were a patient with a weak immune system, any bacteria brought in the hospital from outside could be dangerous or lethal.

What if that nurse was going to help during your surgery wearing the same scrubs. Are not hospitals, and especially surgical rooms, supposed to have everything sterile in them?

actually, hospitals are supposed to make you change into a new set of scrubs before going into surgery. those surgical scrubs are supposed to worn only in surgery. something like that

Scrubs are more evidently worn in the hospital setting, but most physicians wear everyday clothes, not scrubs, and go to restaurants, etc. with those very clothes. Are we suggesting everyone change clothes before going to the supermarket on the way home or eating dinner after work at the hospital? After all, shouldn't those clothes be just as likely to carry the resistant organisms as scrubs?

As a microbiologist/university faculty member who instructs nurses and pre-docs, i can't say enough about how important this discussion is. With the continued rise of antibiotic resistant bacteria as well as incidence of HAIs ( some that are now out in the community) the medical community must recognize that past practices shoild be looked at closely and changed if necessary. Contrary to one of the posts, the organisms can and do remain viable on clothing. Its in the literature. When i move from lab to hallways or classroooms, i always remove my lab coat and wash my hands. This takes little time and eliminates any potential of bringing pathogens into an environment outside of the lab. Physicians and nurses----you are part of the transmission chain re. HAIs. My expectation would be that you should embrace any recommendation that could make your patients or the public less likely to contact pathogens.

As a nursing student I have noticed this practice and was amazed that it goes on in hospital knowing that scrubs and lab coats are covered with pathogens. I recently read a comment from a number of nurses on a site about this subject and a mojority oif comments were stating that wearing your own scubs is your wright and that it takes your independance of freedom away. Also things were said like "germs are germs", i really dont understand this way of thinking as we know as health care workers that some germs " pathogens" are the reason why some of these people are in the hospital in the first place. And we as health care providers, working in close contact with these clients who have sickess from pathogens can lead to spreading these (HAI'S) out into the public. This is why i think that all health care workers who reside or work in the hospital; wether you work as a nurse or a cleaner you should doff and dawn scrubs at work. As the author states, if we know that scrubs are not clean, and there are articles and endless journals that state this, why do we continue to think we cannot spread this out to the public? It should be hospital policy that no person should be able to wear scrubs to or from work, as to try and maintain a steril environment.

Not all healthcare workers are exposed to pathogens. In my work, I am exposed to no more pathogens than a person on a bus. I work with psychiatric and neurology outpatients with no more transmissible disease than anyone else. I don't even have much physical contact with them. I travel to several sites during the day, and I don't have a place or the time to change out of my scrubs between visits or before lunch. I sometimes have up to 2 hours drive before I return home, and I stop to get dinner on the way. We should leave it to the discretion of the professional to determine if they are carrying any biohazards on them. It's an individual responsibility.

Our profession is already regulated more than any other. Doctors are generally responsible people. No need for additional draconian rules that don't necessarily make sense for everybody.

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