Healthcare Triage: Doctors’ White Coats Can Host a Lot of Bacteria
For a lot of doctors and patients, the physician’s traditional white coat is a big part of a doctor’s identity, and contributes to their authority. Those white coats can also spread disease! It turns out, fabrics in doctors coats can be a breeding ground for bacteria, and they probably don’t get cleaned often enough.
A defining symbol of a profession may also be teeming with harmful bacteria and not washed as often as patients might hope.
A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.
Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.
What many might not realize, though, is that health care workers’ attire — including that seemingly “clean” white coat that many prefer — can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.
Both types of bacteria can cause serious problems, including skin and bloodstream infections, sepsis and pneumonia.
It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.
Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours.
Several studies of American physicians found that a majority go more than a week before washing white coats. Seventeen percent go more than a month. Several London-focused studies had similar findings pertaining both to coats and ties.
A randomized trial published last year tested whether wearing short- or- long-sleeved white coats made a difference in the transmission of pathogens. Consistent with previous work, the study found short sleeves led to lower rates of transmission of viral D.N.A. It may be easier to keep hands and wrists clean when they’re not in contact with sleeves, which themselves can easily brush against other contaminated objects. For this reason, the Society for Healthcare Epidemiology of America suggests clinicians consider an approach of “bare below the elbows.”
With the use of alcohol-based hand sanitizer — often more effective and convenient than soap and water — it’s far easier to keep hands clean than clothing.
But the placement of alcohol-based hand sanitizer for health workers isn’t as convenient as it could be, reducing its use. The reason? In the early 2000s, fire marshals began requiring hospitals to remove or relocate dispensers because hand sanitizers contain at least 60 percent alcohol, making them flammable.
Fire codes now limit where they can be placed — a minimum distance from electrical outlets, for example — or how much can be kept on site.
Hand sanitizers are most often used in hallways, though greater use closer to patients (like immediately before or after touching a patient) could be more effective.
One creative team of researchers studied what would happen if dispensers were hung over patients’ beds on a trapeze-bar apparatus. This put the sanitizer in obvious, plain view as clinicians tended to patients. The result? Over 50 percent more hand sanitizer was used.
Although there have been fires in hospitals traced to alcohol-based hand sanitizer, they are rare. Across nearly 800 American health care facilities that used alcohol-based hand sanitizer, one study found, no fires had occurred. The World Health Organization puts the fire risk of hand sanitizers as “very low.”
An article in The New York Times 10 years ago said the American Medical Association, concerned about bacteria transmission, was studying a proposal “that doctors hang up their lab coats — for good.” Maybe one reason the idea hasn’t taken hold in the past decade is reflected in a doctor’s comment in the article that “the coat is part of what defines me, and I couldn’t function without it.”
It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers — including wearable sanitizer dispensers — could help reduce the spread of harmful bacteria.
Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.
It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.
We know it can be hard to persuade physicians to do some things that have proven benefits, such as monitor blood pressure or keep patients on anticoagulants. But it might be even harder to get them to stop doing things.
In May, a systematic review in JAMA Pediatrics looked at the medical literature related to overuse in pediatric care published in 2016. The articles were ranked by the quality of methods; the magnitude of potential harm to patients from overuse; and the potential number of children that might be harmed.
In 2016 alone, studies were published that showed that we still recommend that children consume commercial rehydration drinks (like Pedialyte), which cost more, when their drink of choice would do. We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find. And although there’s almost no evidence that hydrolyzed formulas do anything to prevent allergic or autoimmune disease, they’re still recommended in many guidelines.
Those researchers had reviewed the literature on overuse in children before, looking at all the studies from a year earlier. They modeled the work on a set of papers in JAMA Internal Medicine that looked at overuse in adults through a review of the literature published in 2015, 2014 and 2013.
Overuse is rampant. And it can harm patients.
By the end of the 20th century, for example, research seemed to indicate that we wanted to keep patients in the intensive care unit in a tight range of blood glucose levels. The evidence base for these recommendations came from observational studies that showed that patients with such tight control seemed less likely to develop adverse outcomes like infections or hyperglycemia, and they seemed more likely to survive.
Researchers tested this recommendation prospectively in a randomized controlled trial in a surgical intensive care unit. The results, published in 2001, appeared to confirm the prior findings, that tight glycemic control saved lives.
The study wasn’t perfect. It wasn’t blinded, for instance, and there were downsides to the recommendations. About 5 percent of those who received the intensive therapy had severe hypoglycemia at least once. The mortality in the control group was higher than what might be expected. Finally, this was a study of mostly post-cardiac surgery patients, and it wasn’t clear how widely the findings could be generalized.
Nevertheless, this was a huge benefit, and given the severity of the population being treated (intensive care patients are usually very, very ill), many experts called for changes in treatment while further research was done.
That larger work was published in 2009. The study randomly assigned more than 6,000 patients admitted to an intensive care unit for more than three days — to either tight or traditional glucose control. This time, there was a significantly higher rate of death in the tight control group (27.5 percent vs. 24.9 percent), as well as a much higher rate of severe hypoglycemia (6.8 percent vs. 0.5 percent). These findings applied to patients over all and to subgroups (like surgical versus medical patients).
In light of this, guidelines changed again. Physicians were asked to stop the widespread tight glycemic control.
In 2015, some enterprising researchers set out to look at how this knowledge changed physician behavior. Beginning in 2001, they looked at how physicians adopted the recommendations to use tight glycemic control in patients admitted to intensive care units. Starting in 2009, they looked at how physicians absorbed new information telling them to stop.
From 2001 through 2012, they analyzed data on more than 377,000 admissions to 113 intensive care units in 56 hospitals. Before the first trial was published, in 2001, 17 percent of admissions used tight glycemic control. Beginning in that year, however, there was a slow but steady increase in its use. About 1.7 percent more patients were being treated with recommended practice each quarter.
It’s hard to change behavior, but over time, physicians did. By 2009, the use of tight glycemic control had increased to about 23 percent. Many might have hoped for more, but at least there was progress.
Starting in 2009, however, the reverse was recommended. Doctors were asked to stop. Tight glycemic control was associated not only with higher mortality, but also with more adverse events.
That didn’t happen. From 2009 through 2012, there was no decrease in tight glycemic control. The authors argued that “there is an urgent need to understand and promote the de-adoption of ineffective clinical practices.”
That is, of course, an understatement.
Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, is entirely focused on the identification of care that physicians routinely recommend but shouldn’t. Almost 600 different tests, procedures or treatments, collected over the last six years, are currently listed on their website. Almost all the recommendations basically say “don’t do” them.
This overuse doesn’t provide a benefit. It can lead to harms. It can also cost a lot of money.
The public shares some culpability. Americans often seem to prefer more care than less. But a lot of it still comes from physicians, and from our inability to stop when the evidence tells us to. Professional organizations and others that issue such guidelines also seem better at telling physicians about new practices than about abandoning old ones.
I asked Daniel Niven, the lead author of the 2015 study, why it’s so hard to persuade doctors to discontinue certain practices. He said physicians have a hard time unlearning what they have learned, even when there’s newer and better science available. He said, “Even if the new contradictory science is accepted, providers often struggle applying this information in their daily clinical practice, not because they don’t want to, but rather, because they work within a system that doesn’t adapt well to changing evidence.”
He also said doctors might need to be more thoughtful about prevention: “We need to take a more cautious approach to technology adoption, and learn from mistakes of early adoption of health care technologies based on little or low-quality clinical evidence. This way we can prevent the need to ‘break up’ with the practice when the high-quality evidence shows that it is ineffective.”
Overuse represents a significant problem. As policymakers look for ways to save money without harming quality in the health care system, reducing overuse seems as if it should be a top option.
Hundreds threatened with disciplinary action for opioid scripts to patients who overdosed.
Brian Lenzkes, MD, got a letter last December from the Medical Board of California that left him shocked and scared.
The licensing agency told him it had received a “complaint filed against you” regarding a patient who died of a prescription overdose in May 2013 — four and a half years earlier.
In stern bold type, the letter’s second paragraph said the man “died from an overdose of hydrocodone, oxycodone, and zolpidem.” The state’s prescription drug database, CURES(California Controlled Substance Utilization Review and Evaluation System), showed that “Dr. Brian J. Lenzkes had been prescribing long-term excessive amounts of these, including benzos,” and that “it is unknown what conditions the patient suffered from which required such medication.”
The San Diego internist told MedPage Today he’d tried since 2006 to help this complex patient manage pain related to his many problems — so severe they at one point caused him to be admitted to hospice – including diabetic ulcers, congestive heart failure, severe neuropathy, bone infections, and a below-knee amputation, to name a few, he said.
He’d tapered dosages, changed drugs, and tried many other approaches. Though the patient was challenging, he’d “experienced a strong bond” with him, and “he would often bring me homemade barbecue sauce as a thank-you.”
He knew of no complaints about his care of this man. Lenzkes said the patient’s friend told him the man “would have died years earlier if it were not for my encouragement and support.”
If the medical board was after his license, well, the term “witch hunt” crossed Lenzkes’ mind. “I don’t prescribe inappropriately,” he said.
In fact, no patient or family member had filed a complaint against him.
Hundreds threatened
Rather, Lenzkes is one of hundreds of California physicians caught up so far in the medical board’s aggressive “Death Certificate Project,” a program that attempts to stop the epidemic of accidental deaths from prescription opioid overdoses.
The California project takes death certificates in which prescription opioids are listed as a cause, then matches each with the provider — sometimes more than one — who prescribed any controlled substance to that patient within 3 years of death, regardless of whether the particular drug caused the death or whether that doctor prescribed the lethal dose.
At the project’s launch in late 2015, board staff began reviewing 2,694 certificates of death filed in 2012 and 2013 and found 2,256 matches in CURES, showing each provider who wrote an opioid prescription filled by those deceased patients.
Those reports went to medical peer reviewers who, after extensive review, selected 522 prescribers as warranting an investigation of the patients’ files. They included including 450 allopathic physicians against whom the board has opened formal complaints along with 12 osteopathic physicians and 60 nurse practitioners or physician assistants, who were referred to their respective licensing boards. Of the 12 osteopath referrals, seven were closed for insufficient evidence; the other five remain open for investigation.
Of the nearly 450 MDs like Lenzkes who received letters notifying them of a “complaint,” the state Attorney General has filed opioid-related prescribing accusations against nine physicians, Kirchmeyer said. Four of those nine already faced possible disciplinary action on unrelated charges, and saw their accusations amended with new charges regarding opioid prescribing.
For one physician, the accusation referenced deaths of three patients under his care.
The board said 216 cases involving those 450 MDs have now been closed for insufficient evidence or no violation, or the license had already been revoked or surrendered, or the physician had died. As of last week, 38 still await further review of their cases before proceeding; the rest await completion of an investigation.
“Our goal is consumer protection,” the board’s executive director Kimberly Kirchmeyer told MedPage Today. The board wants to “identify physicians who may be inappropriately prescribing to patients and to make sure that those individuals are educated (about opioid guidelines), and where there are violations of the Medical Practices Act, the board takes (disciplinary) action.”
Addressing her board during its quarterly meeting a year ago, Kirchmeyer described the project as an “invaluable” and proactive way to prevent future opioid overdoses by revealing overprescribers — “rather than have to wait for specific complaints to come in,” which are few and far between.
Coroners are required by law to report pathologist findings indicating a death was due to a physician’s gross negligence or incompetence, but the board had received only nine such reports in the prior 2 years, she said.
The board’s project is using death certificates and the CURES database to go beyond the individual fatality and examine a physician’s overall prescribing practices, Kirchmeyer said.
In some cases, investigations triggered by a death certificate identified other, living patients for whom that provider had possibly inappropriately prescribed, she said. That has resulted in a different letter sent directly to such patients saying that the board “is reviewing the quality of care provided to you by Dr. — ” and asking the patient to promptly authorize the doctor to turn over that patient’s medical records to the board. It also threatens to subpoena the records if the patient refuses.
Asked to address physicians’ concerns that these letters could erode patients’ confidence in their doctors, Kirchmeyer reiterated the goal to improve patient safety and said it only sends such letters to patients after a medical consultant “indicated that a physician may be inappropriately prescribing.”
It’s unclear to what extent other states may be targeting putative overprescribers in this way. A California board spokesman said their program was unique, but North Carolina’s medical board also initiates investigations based on patient fatalities involving opioids.
Specifically, North Carolina’s Safe Opioid Prescribing Initiative probes clinicians who’ve had at least two opioid-related patient deaths in the preceding 12 months and who prescribed at least 30 tablets within 60 days of the patient’s death, or when licensees have large numbers of patients on 100 milligrams of morphine equivalents (MME) per patient per day.
Letter ‘changed my practice’
On that December day, Lenzkes gathered his patient’s thick file and spent the next nights carefully writing six pages of the summary the board expected from him. Finally, nearly 3 months later, board analyst Erika Calderon exonerated him with a terse letter saying the review was complete: “No further action is anticipated and the file has been closed.”
Lenzkes was lucky. He’d kept good notes and was cleared. But, he said, “it changed my practice of medicine.” From now on, he’s referring patients like that one to pain specialists. “I’m not taking any more. That’s just how I feel.”
One physician who knows others who received these letters described it as “terrifying.” A typical response is to immediately contact an attorney and the malpractice insurance carrier.
Many doctors interviewed who received these letters say it has riddled their lives with stress and self-doubt, and then anger when they wait as long as 9 months, or longer, to hear they’ve been cleared.
Ako Jacintho, MD, a family medicine physician and addiction medicine specialist in San Francisco got a similar letter Dec. 11 about his patient who died on March 21, 2012, from “acute combined methadone and diphenhydramine intoxication.” He’d refilled the patient’s prescription for methadone 10 mg the day before, Jacintho said, but never prescribed diphenhydramine, the antihistamine sold as Benadryl.
“Back when my patient died, there was little warning on the dangers of prescribed opioids, and the Medical Board supported the treatment of intractable pain with prescription narcotics…. pharmaceutical companies said prescribed opioids were safe,” Jacintho said. “Methadone was in vogue for treating pain.”
He’s been waiting to hear back now going on 9 months of silence, despite several requests for a determination. It’s caused him loss of sleep and made it difficult for him to focus.
“I feel like I’ve been shamed,” Jacintho said. He started advising physician colleagues to stop prescribing opioids as he considered getting out of medicine altogether. He also hired an attorney.
“If they can’t see that this was me as a physician doing the best job that I could to help this patient with intractable pain, what am I supposed to do?” he asked.
Physician flight
“You can’t even begin to understand how disruptive and upsetting this is,” said Paul Speckart, MD, another San Diego internist who in March received a similar board letter about his patient who died in late 2012. The cause, Calderon’s letter said, in boldface type, was “carisoprodol, lorazepam, oxycodone, zolpidem and trazodone toxicity. Coronary artery atherosclerosis was the only medical condition noted…. Three providers prescribed heavily to this patient and one of them was noted to have been you.”
Speckart’s eight-page response went back to 1998 in which he documented his many refusals to give the patient scheduled drugs and his efforts to refer her to a pain specialist. In July, Calderon wrote Speckart “there was no problem” with his treatment of that patient, but “your overall pattern of prescribing opioids looks excessive.” He was told to read the guidelines issued by the board in 2014 and the CDC in 2016 and on prescribing controlled substances for pain, which he did.
He does not overly prescribe, he said. The few for whom he does prescribe opioids genuinely need pain relief for their multiple conditions.
As chair of a San Diego County Medical Society’s Emergency Medicine Oversight Commission, emergency room doctor Roneet Lev, MD, heard the physicians’ outcries. “We’ve definitely heard physicians say, ‘I’m done. I’m not going to see these patients; I don’t need this headache.’ And that’s left California without the doctors we need to treat these patients,” Lev said.
Her own study, published earlier this month in the journal Science, tested a gentler approach — a letter directly from the San Diego County medical examiner notifying physicians that a patient they treated died of an opioid overdose, rapidly informing them what happened to their patients. It served as an informed warning, unlike the medical board’s implied threat of disciplinary action.
Lev’s study found that within 3 months of receiving those letters, those physicians prescribed nearly 10% fewer opioid drugs compared with physicians in a control group who were not sent a medical examiner’s letter.
She said the medical board’s approach is “alarming” for several reasons. For starters, most physicians did not have easy access to the CURES database before 2014 to see what other drugs their patients had been prescribed by other providers, a concern since most patients who overdosed did not do so on one drug alone. Mandatory reporting for the system does not start until Oct. 1, 2018.
Second, at the time, there was no uniform standard on the total morphine equivalent dosage doctors should be prescribing, or how much is too much had been in dispute.
Third, the medical board’s approach is simply unrealistic, she said. “You have to remember, there’s still thousands of Americans who are on high-dose opioids, and you can’t just cut them off. They need to be weaned. Our job is to taper them to be safe.”
Lev said she reached out to Ted Mazer, MD, California Medical Association president, and Kelly Pfeifer, director of the California Health Care Foundation’s High-Value Care staff. She hoped to persuade the board to restructure the Death Certificate Project as an educational tool. Otherwise they worry that physicians will fear disciplinary action so much they feel they must hire lawyers, decide to stop taking patients, or refuse to prescribe pain relief.
The California Academy of Family Physicians declined to comment on the board’s project when approached by MedPage Today, but its web page sternly advises doctors to protect themselves by consulting and retaining an attorney “immediately upon contact” from the board regarding a patient who overdosed. “At no point during an investigation should a family physician be without legal counsel,” the organization said.
The California Medical Association’s associate director, Charlie Lawlor, said his group “remains committed to our continued work on effective policies that increase access to proven treatments for patients with addiction and dependency,” but is still reviewing the board’s program and wouldn’t comment on the merits of the project.
Kirchmeyer sought to refute arguments against the program’s tactics. She said all prescribers were held to the standard of care that was in place in 2012 and 2013. The medical board believes in its current approach because the CURES database shows that many deceased patients had received controlled substances from more than one prescriber, she said, and “it’s unclear whether any of these providers were actually aware that their patients were using multiple prescribers.”
Letter toned down
One criticism of the program, that the letters to physicians were far too threatening and inaccurately implied a family member had filed a “complaint,” has resulted in a major rewording, “based on feedback we received from doctors and consumers,” Kirchmeyer said.
Instead of telling them the board received a “complaint,” new letters sent this summer specify the source — records from the state Department of Public Health — and explain that the inquiry is meant to reduce “the alarming number of overdose deaths.”
It specifies that the review is “routine,” and stresses that “just because a patient death occurred, it does not automatically mean the physician deviated from the standard of care.”
Lenzkes, Jacintho, and Speckart said in separate interviews that the board is right to be concerned about overprescribing. “There’s a lot of abuse, we all agree,” Speckart said.
Added Lenzkes: “When you hear a bunch of doctors all at the same time all getting the same letter, and you realize they’re going through the same thing, you see why some are saying [to patients], ‘Sorry, if you have a lot of medical conditions, we’re not going to take care of you.'”
HENRY KOTULA 