Bow tie or no tie: a rule to reduce healthcare-acquired infections

I cannot believe we are back here and missing school again; we were just here last week for his yearly check-up and he was fine, but someone was sneezing and coughing in the waiting room. Then you guys gave him his shots, and now he has fever, cough, and a cold. It seems like every time we bring him to the doctor he gets sick.

Halfway through my rural medicine rotation at the pediatric clinic, I began to recognize this frustrating story as one of the more common reasons behind a sick-child visit. It seemed to be a daily occurrence that a child or two who had been in good health and had recently visited our clinic for a health maintenance examination had subsequently fallen ill, and the blame was always laid at our feet. We would always attempt to reassure our patients and their families that children will likely become ill regardless of the best precautions as they have contact with sick children at home and school, they touch and eat anything and everything, and there are no data to support that vaccines cause illness. Despite these and other reassurances, the frequency with which patients presented with this complaint made it impossible to ignore the alarming reality of healthcare-acquired infections.

In 2009, the Center for Disease Control reported that close to 5% of patients acquire infections during the course of their healthcare visits and estimated that these infections account for a yearly price tag in the 30 billion to 40 billion dollar range (1). This article further postulated that preventing a mere 20% of these unnecessary infections could result in savings of 6 billion to 9 billion dollars (1). Even more recently, a study was published in January 2014 from the Society for Healthcare Epidemiology of America concerning physician attire and its role in healthcare-acquired infections (2). This paper had guidelines for physicians and other healthcare providers to decrease the transmission of diseases. It made several recommendations including a ‘bare-below-the-elbow' rule; frequent laundering of white coats; recommendations against neckties, watches, and jewelry; and strongly encouraged scientists to design and carry out appropriate and relevant studies to further elaborate the major offenders and propose solutions or alternatives (3).

As someone who recently swore the physician oath, swearing to ‘do no harm’, I recognized the urgency and duty we have to improve in this area. Additionally, as a new physician who will practice medicine during an era that will certainly be affected by the changing climate of healthcare and decreasing compensations, I have a financial motivation in addition to the public health responsibility to participate in the fight against infectious diseases.

Considering the contagious nature of most infections, I began to think about what could be done to mitigate the spreading of disease. Throughout my medical training I have been fortunate to have the opportunity to observe a multitude of supremely qualified and excellent healthcare providers interact with patients, learning something from all of them. I have found one area in which I believe a simple change can go a long way and make a tremendous difference in the fight against communicable diseases.

Shortly after beginning medical school, I started my Introduction to Clinical Medicine Rotation, a longitudinal experience designed to prepare freshmen medical students to talk to and examine patients. In the very first session, I observed a physician leaning over a patient to perform an examination and his necktie made contact with the patient and several other items. When I questioned my preceptor regarding this and proposed that we be allowed to skip the necktie, he offered me three choices: 1) tuck the tie into my shirt while examining patients, 2) wear a tie clip, or 3) wear a bow tie. I disliked the first two choices as they did not entirely eliminate what I perceived as the offending agent, so a fellow classmate and I decided to adopt the policy of ‘bow tie or no tie' for all our future clinical rotations.

Extending this concept more broadly, in between every patient visit there are several things that happen in each examination room. The table cover is changed, some of the noticeably dirty equipment is cleaned, and freshly laundered gowns are provided for the patients to change into. However, various medical instruments, computers for electronic medical records, and the providers themselves all remain in their same uncleaned state.

Certain tools of the trade, such as stethoscopes, are undoubtedly essential for performing a physical examination, and clearly do more good than bad. Conversely, there are things that he healthcare provider can bring to the bedside that are unnecessary and potentially dangerous. Although our hands are clean and our skin is cracking from the frequent alcohol rubs, the rest of our person is essentially a mobile fomite, an object capable of carrying or transmitting infectious organisms. People (should) wash their hands regularly, wear clean clothes to work, and even shy away from wearing their white coats, yet rarely does someone wash a necktie before wearing it.

Several common objects have already been studied to determine their roles in transmitting infections, including stethoscopes, neckties, personal electronics, white coats, and pens. Interestingly, a case-control study was done to evaluate the colonization rate of purses of female doctors who work clinically in hospitals compared to purses of females who had not been to a hospital in 6 months. This study found that 9 of 13 female physicians' purses were colonized, whereas only 2 of 14 non-physicians had bacteria growth in their purses (4). Although there are several limitations, including an inability to establish a causal relationship and an insignificantly small sample size, this study still suggests that our apparel and accessories can act as fomites.

I believe that the necktie that physicians wear is one of the most serious offenders when it comes to physician-transmitted infections. Neckties frequently come into contact with germs and human secretions, becoming mobile petri dishes that follow the wearer everywhere. One study done in a New York hospital demonstrated that one out of every four male healthcare providers' neckties carried Staphylococcus aureus, and one in eight carried bacteria associated with the more serious hospital-acquired infections, including Pseudomonas aeruginosa, Klebsiella pneumonia, and Acinetobacter baumanii (5). This same study found that a physician's necktie was eight times more likely to be colonized than the controls of the study, the hospital's security staff (5).

An argument against eliminating neckties that I have come across in my literature searches and in my clinical experience is the need for a necktie as an object of professionalism to strengthen and validate the patient-doctor relationship. Some feel that patients will be more trusting of a more professionally dressed individual, as well as perceive that they received better care. One study that suggested otherwise found no difference in patient satisfaction whether the physician was wearing business clothes, casual clothes, or scrubs (6).

In a study investigating parental preference for their child's emergency physician's choice of clothes, they concluded that close to 70% of people surveyed did not care what their provider wore. However, when pressed to choose they did have preferences (7). Although the majority did then prefer the more formal attire, they conceded that it did not affect their perception of the physician's competency (7). Interestingly, these preferences changed if it was a surgical emergency (scrubs were preferred) and if the visit was during the overnight shifts (less formal was more acceptable) (7). I believe that the take-home point from this study is that if all else is equal people will always have their preferences, yet at the end of the day, they are perfectly satisfied with quality care regardless of the way it is presented. I imagine the answers to these above-mentioned survey questions could change significantly after a short educational session on the dangers of wearing white coats and neckties, and this represents an area that could benefit from future research.

On the topic of perception, from my own personal experiences, walking through a hospital as a student wearing scrubs sans white coat I have been called ‘doctor' far too many times to count. Conversely, I have seen female physicians addressed as ‘nurse' countless times, despite professional dress and white coats with name tags visible. This has even happened after they introduced themselves using the title ‘doctor'. I believe that this is a perfect example of how people have their own inherent biases and do not necessarily associate a particular style of dress with a title or position. Effective communication can go a long way to counter this as in the way I correct people and tell them what my role is, so too a simple sign reading ‘Neckties are against the dress code for health reasons' would surely mollify any hard-liners who demand formal attire.

In the same capacity with which doctors must be responsible stewards of resources and weigh the benefit of any diagnostic lab, imaging, or therapies against the possible negative side effects, the same must be done with our persons, specifically our uniforms. Considering how little the necktie adds to the patient-doctor relationship in today's world, and the incidence in which it can transmit deadly bacteria, I believe that a necktie is nothing more than a physician endorsed fomite, and I propose to eliminate the necktie from a physician's clinical uniform.

Although I chose to focus on eliminating the necktie, I would be remiss not to mention that I believe this concept has broader applications. Anything that consistently serves as, or has the potential to act as, a repeat offender should be strongly evaluated for what benefit it adds, and steps taken to decrease its bacterial load or remove it from settings where it can endanger others. There is certainly more that can be done in this fight against spreading infection. A randomized, double-blind, controlled clinical trial is a great way to obtain scientifically sound data, but there are simpler measures that we can implement, using our clinical judgment (as we do in our clinics on a daily basis) that can go a long way. I believe establishing and enforcing a rule of ‘bow tie or no tie' for physicians and other healthcare providers would diminish the incidence of colonization and hopefully lead to a reduction of healthcare-associated illnesses, not to mention the potential billions of dollars in costs it can eliminate, and certainly merits further research.

Andrew S. Frei, MD
Department of Emergency Medicine
York Hospital
York, PA, USA
Email: afrei@wellspan.org