Doctors Need to Stop Wearing Ties

I always considered neckties to be sacred. In my mind, learning to tie this long piece of cloth around my neck was a fast track to dapperness. As I entered medical school, the necktie that adorned my short, student white coat promised to make me appear more doctor-esque despite my middling and inchoate abilities. I also hoped its carefully selected skinny-ness would add a touch of style to my bland hospital attire.

But somewhere along the way, I shed my necktie. In the interminable and exacting hours of residency training, it began to resemble a noose that became increasingly suffocating throughout the day. More so, it seemed like a relic from a previous era of medicine—one that might have emphasized physical appearance due to the limits of scientific capabilities.

In healthcare, neckties are the great polarizer. A cursory scan of the hallways of teaching hospitals reveals a generational difference. Unless mandated to wear ties by program or hospital leadership, younger physicians appear strongly partial to open-collar shirts. Senior physicians opt for a more formal appearance that always begins with a tie and sometimes consists of a blazer or business suit.

"We were required to wear ties by our program director, who hoped to instill a sense of professionalism into us," says Ashwin Chandar, a hematology/oncology fellow at the Rutgers Cancer Institute of New Jersey. "But they are generally uncomfortable and feel more constricting as the day progresses, especially in the context of a profession that often requires physical exertion, such as performing procedures and chest compressions."

Yet this is not just about discomfort. It's about infection, too. While no clinical studies have demonstrated cross-transmission of bugs from a professional to a patient via neckties, they have been found to be contaminated by potentially pathogenic bacteria and to be possible sources for physician-transmitted infections. As Andrew S. Frei wrote in the Journal of Community Hospital Internal Medicine Perspectives, "Neckties frequently come into contact with germs and human secretions, becoming mobile petri dishes that follow the wearer everywhere." Bet you'll never look at a doctor's tie the same again.

A 2004 study at the New York Hospital Medical Center of Queens cultured the neckties of doctors and medical students. Nearly half (46.7 percent) were found to harbor potentially infectious bacteria. Several other studies have isolated Staphylococcus aureus and organisms associated with more unforgiving hospital-acquired infections like methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Klebsiella pneumoniae and Acinetobacter baumannii from the neck accessory. Two reports noted that up to 70 percent of physicians conceded that they never cleaned their ties. (Side note: I cleaned mine.)

Further, physician white coats and nursing uniforms were noted to be homes to serious pathogens such as Acinetobacter species, Enterobacteriaceae and Pseudomonas species. Virulent organisms like vancomycin-resistant enterococci (VRE), MRSA and Clostridium difficile (C. diff) were also seen on the hospital attire.

In isolation, the implications of this bacterial colonization of attire are not easy to discern. But in the context of growing antibiotic resistance and troubling rates of healthcare-associated infections (infection acquired while receiving medical care in a healthcare facility), neckties become a potential risk factor that can be readily eliminated.

Currently, bacteria resistant to colistin, which is known as the "antibiotic of last resort," are showing a marked increase globally. Given the harrowing trend, Sally Davies, England's chief medical officer, said at a meeting of the American Society for Microbiology, "The world is facing an antibiotic apocalypse."

Furthermore, according to the CDC, on any one day, about 1 in 25 hospital patients has at least one healthcare-associated infection (HAI). In 2011, there were approximately 722,000 HAIs in US acute care hospitals, and about 75,000 patients with HAIs died during their hospitalizations.

Despite medicine's historical predilection for a dress code that projects professionalism, neckties aren't deemed essential by patients. Studies and surveys from the United Kingdom have increasingly shown that patients do not expect ties on their doctors, as trust and confidence are not contingent on a piece of cloth. Furthermore, when patients are informed of potential risks associated with certain types of attire, they are more lenient in their preferences for a physician's appearance.

Though large prospective trials will be needed to further elucidate the link between a healthcare worker's sartorial choices and HAIs, Gonzalo Bearman, a leading researcher on the topic and chair of Virginia Commonwealth University's Division of Infectious Diseases, feels prudent precautions should be taken based on "biological plausibility, simplicity and the likelihood of not causing harm." While the concept has gained little traction in previous years, he says that it is now "gaining some momentum in US hospitals."

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