Category: Feature Articles

Introduction

Cannabis was first used in China around 6,000 years ago and is one of the oldest psychotropic drugs known to man. [1] There are several species of cannabis, the most common are Cannabis sativa, Cannabis indica and Cannabis ruderalis. [2] The two main products that are derived from cannabis are, hashish – the thick resin of the plant, and marijuana – the dried flowers and leaves of the plant. [1] Cannabis contains over 460 chemicals and 60 cannabinoids (chemicals that activate cannabinoid receptors in the body). [1,2] The major psychotropic constituent of cannabis is known as delta-9-tetrahydrocanabinol (THC); others include cannabinol and cannabidiol (CBD).

Cannabinoids exert their effect throughout the body through binding with specific cannabinoid receptors. There are two types of cannabinoid receptors found in the body: CB₁ and CB₂. Both are G-protein coupled plasma membrane receptors. The CB₁ receptors are mostly found in the central nervous system, whilst CB₂ receptors are mainly associated with immunological cells and lymphoid tissue such as the spleen, tonsils, and thymus. [3,4]

Delta-9-tetrahydrocanabinol (THC) and other cannabinoids are strongly lipophilic and are rapidly distributed around the body. [5] Because of its strong lipophilic nature cannabinoids accumulate in adipose tissue and have a long elimination time of up to 30 days, although the psychoactive effects generally wear off after a few hours. Medical cannabis can be dispensed and taken in a variety of ways including as a herbal cigarette, ingestible forms, or as herbal tea. However, marijuana cigarettes are commonly preferred as they provide higher bioavailability. [5]

Medical marijuana users represent a large range of ages, levels of education attainment, employment statuses, and racial groups. [6] A Californian study examining medical marijuana use showed 76.6% of medical marijuana users use seven grams of marijuana or less per week. Therefore, the majority of medical marijuana users are likely to consume amounts equivalent to mild to moderate recreational cannabis use. [6]

The rescheduling of cannabis in Australia draws strong debate and opinions from both sides of the issue. This article will provide an overview of the most popular arguments for and against the legalisation of cannabis for medicinal purposes.

The legal status of medical marijuana in Australia

Currently cannabis is a Schedule nine drug in all Australian states and territories, placing it in the same category as drugs like heroin and lysergic acid diethylamide (LSD). [7] Legally, drug scheduling in Australia is a state issue, however, all states abide by the federal government’s scheduling of cannabis as a Schedule nine drug, as per the Standard for the Uniform Scheduling of Medicines and Poisons. [7,8] The use of a drug which is classified as Schedule nine for recreational or medical purposes is illegal and a criminal offence. Research into cannabis in Australia is highly restricted. [7] Cannabis use is common in Australia with approximately 40% of Australians aged fourteen years or older saying they have used cannabis, and over 300,000 Australians using it daily. A number of Australians are already self-medicating with cannabis for a range of complaints including chronic pain, depression, arthritis, nausea, and weight loss. However, these people risk legal action from authorities, particularly if cultivating their own cannabis. Moreover, if they purchase cannabis from a dealer they also face quality and supply issues. [9] Proponents of medicinal cannabis envisage a system similar to other drugs of dependence, like opiates, whereby holders of a valid prescription will be able to purchase or access the drug but where recreational use of the drug would still be illegal.

A number of countries have decriminalised cannabis for medical purposes such as the Netherlands, Israel, eighteen states in the United States of America (USA), Canada and Spain. [10] However, the drugs known as Dronabinol (containing just THC), Nabilone (containing a synthetic analogue of THC) and Nabiximols (a spray containing CBD and THC) are available as Schedule eight drugs throughout Australia. [7] Schedule eight drugs are drugs which have a high likelihood for abuse and dependence and require regulation in their distribution and possession. [7,8] However, some claim that these preparations lack many of the cannabinoids found in natural cannabis plants and this leads to different physiological and therapeutic effects compared to natural cannabis. [4] Public support in Australia for medical cannabis is very high with a survey finding 69% of the public supporting the use of medical cannabis and 75% supporting more research into the medical potential of the drug. [11]

Arguments for legalisation

Pain relief

Marijuana has potent analgesic properties which can be used in pain relief for a variety of conditions that can cause intense pain, such as cancer pain and acquired immunodeficiency syndrome (AIDS). Marijuana may even provide superior pain relief when compared to opiates and opioids. A parallel study in the United Kingdom (UK) compared the use of a THC and CBD extract, a THC only extract, and a placebo in the treatment of cancer pain. It found that a THC:CBD mixture (such as that found naturally in the cannabis plant) is efficacious for the relief of advanced cancer pain that is not adequately controlled  by opiates alone. [4] Therefore, the legalisation of medical cannabis could relieve pain and improve the quality of life for severely ill patients suffering from a range of painful conditions.

Appetite stimulation

It has been proven in animal studies that THC can have a stimulating effect on appetite and lead to an increase in food intake. [2,5,12,13] There are a large number of clinical applications for THC for appetite stimulating purposes. Conditions which can cause cachexia (uncontrolled wasting) such as HIV/AIDS, cancer, multiple sclerosis (MS), could be treated with THC to stimulate the patient’s appetite, increase food uptake, restore weight, and improve the strength and wellbeing of the patient. [2,13] Human trials in the 1980s which involved healthy control subjects inhaling cannabis found that the cannabis caused an increase caloric intake of 40%. [14] The legalisation of cannabis for medical purposes could help improve both health outcomes and the quality of life in patients suffering from a range of conditions.

Anti-emetic

In Canada and the USA, dronabinol and nabilone have been used in the treatment of chemotherapy induced nausea and vomiting since the 1980s. [15] A systematic literature review found that cannabinoids were more effective than established anti-emetic drugs in its treatment. [16] By reducing or eliminating the often debilitating and painful symptoms of chemotherapy induced nausea and vomiting, medical cannabis is hoped to improve the quality of life for the patient and their family. A reduction in the vomiting and pain associated with chemotherapy may also cause an increase in adherence to chemotherapy by cancer patients and result in better patient outcomes. [2,13] Therefore, the rescheduling of cannabis could prove as a highly effective anti-emetic for cancer patients and could even improve their prognosis by encouraging adherence to chemotherapy.

Neurological conditions

Cannabis may also be used to lessen or alleviate an entire range of symptoms associated with MS and other neurological conditions. A Canadian randomised, placebo-controlled trial investigating the use of smoked cannabis for MS-related muscle spasticity found that cannabis was superior to the placebo in reducing pain and spasticity. [17] Another trial conducted in Canada on the use of smoked cannabis for chronic neuropathic pain found that an inhalation of the cannabis formulation prepared for the trial three times daily for five days reduced pain intensity, improved the quality of sleep, and had minimal adverse effects. [18] The legalisation of medical cannabis could therefore make a significant difference to the lives of the thousands of Australians suffering MS and many other neurological conditions.

Safety and overdosing

Cannabis may also serve as an incredibly safe alternative to groups of medications prescribed for pain, such as opiates. The CB₁ cannabinoid receptors are the main receptors responsible for the analgesic effects of cannabis and are located in the brain. However, they are in very low numbers in the regions of the brain stem co-ordinating cardiovascular and respiratory control. [2,19] This means it is essentially impossible to overdose from cannabis. [5] However, opioid receptors are located in this brain stem region hence signifying that opioids can interfere with cardiovascular and respiratory functions and lead to death. [19,20] Prescription opioid deaths are a small but concerning issue throughout developed nations. For example, in 2005 there were over 1,000 deaths related to prescribed oxycodone in the US. [20] Medical marijuana may offer a safer alternative form of pain relief as it removes the risk of accidental overdose which can lead to death.

Arguments against legalisation

Cannabis use and psychiatric disorders

A longstanding argument against the medical use of cannabis has been that exposure to cannabis can lead to the development of psychiatric disorders, namely schizophrenia. A Scottish systematic review of eleven studies investigating the link between marijuana use and schizophrenia supported this view and found that cannabis use did appear to increase the risk of schizophrenia. [21] Another study has also shown that there is an association between heavy cannabis use and depression. [22] Further effects of cannabis induced psychosis can include self-harming and self-mutilating behaviours. [23,24] The relationship between cannabis use and mental health issues appears to be dose-related with higher amounts of marijuana use related to more severe psychiatric complications. [21,22] Some say it would be unethical to prescribe a patient cannabis when there is a risk of the patient developing mental illness and potentially harming themselves or others. Particularly, when there are other drugs available without such adverse effects on mental health and stability.

Public safety

With the legalisation of medicinal cannabis come clear public safety concerns, particularly in the areas of vehicle and pedestrian safety. Cannabis affects the brain and can cause feelings of disorientation, altered visual perception, hallucinations, sleepiness, and poorer psychomotor control. [5,19] A study conducted in California found that on a particular evening, 8.5% of motorists had THC in their system and that holders of a medical cannabis permit were significantly more likely to test positive to THC than those who did not hold a permit. [25] It has also been shown that drivers using cannabis had about three to seven times the risk of being in a motor car collision than drivers who were not using cannabis. [26] However, it is interesting to note that those driving under the influence of alcohol were at a higher risk of having a collision than those using cannabis. [27] Also interesting is the fact that after medical marijuana programs were instituted in the US, traffic fatalities decreased nine percent across the sixteen states which had programs at the time of the study; this is believed to be due to a substitution of alcohol with marijuana. [27,28] Pedestrians and cyclists who are prescribed cannabis are also at higher risks of being injured in a collision. In terms of non-vehicular injuries, an American study showed cannabis use was associated with an increased risk of injuries from causes such as falls, lacerations, and burns. [29] Hence the legalisation of medical cannabis not only poses a risk to the personal safety of the patient but also to the physical safety of the wider community.

Drug diversion

Given the popularity of cannabis as a recreational drug, there is always the risk of wide scale drug diversion occurring–that is people without a prescription for cannabis gaining access to the drug. This can happen in a number of ways like a patient sharing their medication with others or the patient selling their medication. In America diversion of medical marijuana is an increasing issue, particularly amongst adolescents. A study in the state of Colorado in the USA found that out of a group of 164 adolescents at a substance abuse treatment facility, 74% had used someone else’s medical marijuana, with the mean number of times the adolescents had used someone else’s medical marijuana being over 50. [30] Illicit use of cannabis for non-medical purposes exposes people to the damaging physical, mental and social impacts of drug use. There are clear questions surrounding how this would be prevented and how young adults especially could be prevented from accessing cannabis due to diversion. It must be asked whether it is ethically responsible to reschedule marijuana given that such a large number of other people, particularly adolescents, will have access to someone else’s medical cannabis.

Addictiveness and dependence

The legalisation of cannabis as a medication has the potential to cause patients to develop an addiction to the drug and possible dependence. Cannabis dependence is a recognised psychiatric disorder and it is estimated that over one in ten people who try marijuana will become addicted to it at some point. [31] Although dependence to marijuana may be lower than other drugs like, heroin, cocaine and alcohol, users can still face withdraw symptoms including sleep difficulty, cravings, sweating and irritability. [5,32] With the potential of people becoming addicted to medical cannabis and with scarring consequences for their personal life some say it is ethically questionable to subject people to it in the first place.

Availability of cannabinoid and synthetic cannabinoid drugs

Those opposed to cannabis being rescheduled for medical purposes claim that the availability of cannabinoid and synthetic cannabinoid drugs already in Australia namely, Dronabinol, Nabilone and Nabiximols, makes legalising medical cannabis unnecessary. They state that these drugs contain many of the same compounds as cannabis and can be used for treating many of the same conditions. [13] For example, Dronabinol has been shown to be effective in relieving patients suffering chronic pain which is not fully relieved by opiates. [33] Therefore, the cannabinoid medications which are already available in Australia may provide many of the same therapeutic benefits offered by cannabis, and as such rescheduling cannabis would be unnecessary.

Carcinogenicity

Whether marijuana smoke causes cancer, in particular lung cancer, is a subject of much debate and research itself. It is well established that tobacco smoke is carcinogenic and deeply damaging to overall health. [34] With marijuana containing many of the same carcinogens as tobacco, and often being in cigarette form, it is not unreasonable to expect similarly adverse results with cannabis use. [5,35] However, a case-control study by Hashibe et al. [36] found that there was not a strong relationship between marijuana use, even in heavy amounts, and the incidence of oesophageal, pharyngeal, laryngeal, and lung cancer. Some evidence exists, showing that cannabinoids may in fact kill some cancers such as gliomas, lymphomas, lung cancer and leukemia. [37-39] Despite evidence that marijuana smoke contains mutagenic and carcinogenic chemicals, epidemiologically this was not confirmed to be the case. [35,36] Overall the carcinogenic or cancer-fighting properties of marijuana remain unclear and contradictory. More long-term, large population research should be conducted so that the seemingly contradictory nature of the drug can be better understood. [36]

Recommendation

Cannabis offers exciting possibilities for patients afflicted by cancer, HIV/AIDS, MS, chronic pain and other debilitating conditions. Although medical marijuana programs face several obstacles, the benefits offered by medical marijuana and the positive impact this drug could have on the lives of thousands of patients and their families make a strong case for its consideration. The potential drawbacks can be minimised or even overcome through a number of measures, including: the close medical supervision of patients (e.g., proper patient education and monitoring), the creation of  appropriate infrastructure (e.g., medical marijuana dispensaries, as seen in California) and the creation of laws and policies that are not only supportive of medical marijuana patients but will also, minimise the risk the drug poses to the public (e.g., strict penalties for medical marijuana diversion).

Conflict of interest

None declared.

Correspondence

H Smith: hamish.smith@y7mail.com

References

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[2] Amar MB. Cannabinoids in medicine: A review of their therapeutic potential. Journal of Ethnopharmacology. 2002;105(1):1–25.

[3] Sylvaine G, Sophie M, Marchand J, Dussossoy D, Carrièr D, Caryon P, et al. Expression of central and peripheral cannabinoid receptors in human immune tissues and leukocyte subpopulations. Eur J Biochem. 2005 Apr;232(1):54–61.

[4] Johnson JR, Burnell-Nugent M, Lossignol D, Gaena-Morton ED, Potts R, Fallon MT. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC: CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage. 2010 Feb;39(2):167-79.

[5] Ashton CH. Pharmacology and effects of cannabis: A brief review. Br J Psychiatry. 2001 Mar:178(2):101-6.

[6] Reinarman C, Nunberg H, Lanthier F, Heddleston T. Who are medical marijuana patients? Population characteristics from nine California assessment clinics. Journal of Psychoactive Drugs. 2011 Jul 43;2:128-35.

[7] National Drugs and Poisons Schedule Committee. Standard for the uniform scheduling of drugs and poisons No. 23. Canberra (ACT): Therapeutic Goods Administration; 2008 Aug. 432 p.

[8] Moulds RF. Drugs and poisons scheduling. Aust Prescr [Internet]. 1997 [Cited 7 Feb 2013];20:12-13. Available from: http://www.australianprescriber.com/magazine/20/1/12/3#qa

[9] Swift W, Hall W, Teeson M. Cannabis use and dependence among Australian adults: Results from the national survey of mental health and wellbeing. Addiction. 2001 May;96(5):737–48.

[10] Marijuana Policy Project (MPP). The Eighteen States and One Federal District With Effective Medical Marijuana Laws. Washington (DC): MPP; 2012 Dec. 19 p.

[11] National Institute of Health and Welfare. The National Drug Strategy Household Survey 2011. Australian Government: Canberra. 2012.

[12] Mechoulam R, Berry EM, Avraham Y. Endocannabinoids, feeding and suckling- from our perspective. Int J Obes. 2006 Apr; 30(1):24-8.

[13] Robson P. Therapeutic aspects of cannabis and cannabinoids. Br J Psychiatry. 2001 Feb;178:107-15.

[14] Foltin RW, Fischman MW, Byrne MF. Effects of smoked marijuana on food intake and body weight of humans living in a residential laboratory. Appetite. 1988 Aug;11(1):1-14.

[15] Sutton IR, Daeninck P. Cannabinoids in the management of intractable chemotherapy-induced nausea and vomiting and cancer-related pain. J Support Oncol. 2006 Nov;4(10):531-5.

[16] Tramèr MR, Carroll D, Campbell FA. Cannabinoids for control of chemotherapy induced nausea and vomiting: Quantitative systematic review. BMJ. 2001 Jul;323(7303):16-21.

[17] Corey-Bloom J, Wolfson T, Gamst A. Smoked cannabis for spasticity in multiple sclerosis: A randomized, placebo-controlled trial. CMAJ. 2012 Jul;184(10):1143-50.

[18] Ware MA, Wang T, Shapiro S. Smoked cannabis for chronic neuropathic pain: A randomized controlled trial. CMAJ. 2010 Oct;182(14):694-701.

[19] Adams IB, Martin BR. Cannabis: Pharmacology and toxicology in animals and humans. Addiction. 1996 Nov;91(11):1585-1614.

[20] Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006 Dec;31(6):506-11.

[21] Semple DM, McIntosh AM, Lawrie SM. Cannabis as a risk factor for  psychosis: Systematic review. J Psychopharmacol. 2005 Mar;19(2):187-194.

[22] Degenhardt L, Hall W, Lynskey M. Exploring the association between cannabis use and depression. Addiction. 2003 Nov;98(11):1493-1504.

[23] Khan MK, Usmani MA, Hanif SA. A case of self amputation of penis by cannabis induced psychosis. J Forensic Leg Med. 2012 Aug;19(6):355-7.

[24] Serafini G, Pompili M, Innamorati M, Rihmer Z, Sher L, Girardi P. Can cannabis increase the suicide risk in psychosis? A critical review. Curr Pharm Des. Jun 2012;18(32):5165-87.

[25] Johnson MB, Kelley-Baker T, Voas RB, Lacey JH. The prevalence of cannabis-involved driving in California. Drug Alcohol Depend. Jun 2012;123(1-3):105-9.

[26] Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend. 2004 Feb;73(2):109-19.

[27] Sewell RA, Poling J, Sofuoglu M. The effect of cannabis compared with alcohol on driving. Am J Addict. 2009;18(3):185-93.

[28] Anderson DM, Rees DI. Medical marijuana laws, traffic fatalities, and alcohol consumption. Denver (CO): Institute for the Study of Labor. 2011  Nov. 28 p.

[29] Gerberich SG, Sidney S, Braun BL, Tekawa IS, Tolan KK, Quesenberry CP. Marijuana use and injury resulting in hospitalisation. Annals of Epidemiology. 2003 Apr;13(4):230-7.

[30] Salomonsen-Sautel S, Sakai JT, Thurstone C, Corley R, Hopfer C. Medical marijuana use among adolescents in substance abuse treatment. J Am Acad Child Adolesc Psychiatry. 2012 Jul;51(7):694–702.

[31] Hall W, Degenhardt L, Lynskey M. The health and psychological effects of cannabis use. Canberra (ACT): Commonwealth Department of Health and Ageing; 2001.

[32] Budney AJ, Vandrey R, Moore BA, Hughes JR. Comparison of tobacco and marijuana withdrawal. J Subst Abuse Treat. 2008 Dec;35(4):362-68.

[33] Narang S, Gibson D, Wasan AD, Ross EL, Michna E, Nedeljkovic SS, et al. Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy. The Journal of Pain. 2008 Mar;9(3):254-64

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[35] Hecht SS, Carmella SG, Murphy SE, Foiles PG, Chung FL. Carcinogen biomarkers related to smoking and upper aerodigestive tract cancer. J Cell Biochem Suppl. 1993 Feb;17(1):27-35.

[36] Hashibe M, Morgenstern H, Cui Y, Tashkin DP, Zhang ZF, Cozen W, et al. Marijuana use and the risk of lung and upper aerodigestive tract cancers: Results of a population-based case-control study. Cancer Epidemiol Biomarkers. 2006 Oct;15(1):1829.

[37] Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA. Antineoplastic activity of cannabinoids. J Natl Cancer Inst. 1975 55:597-602.

[38] McKallip RJ, Lombard C, Fisher M, Martin BR, Ryu S, Grant S, et al. Targeting CB2 cannabinoid receptors as a novel therapy to treat malignant lymphoblastic disease. Blood. 2002;100:627-34.

[39] Sanchez C, de Ceballos ML, del Pulgar TG, Rueda D, Corbacho C, Velasco G, et al. Inhibition of glioma growth in vivo by selective activation of the CB(2) cannabinoid receptor. Cancer Res 2001, 61:5784-89.

 

 

Should we bring back the white coat? Is it time for this once-venerated symbol of medicine to re-establish itself amongst a new generation of fledgling practitioners? Or, is this icon of medical apparel nothing more than a potentially dangerous relic of a bygone era?

Introduction

The white coat has long been a symbol of the medical profession, dating back to the late-1800s. [1] It was adopted as medical thought became more scientific. [2] Doctors wore coats aligning themselves with the scientists of the day, who commonly wore beige coats, but instead chose white – the colour lacking both hue and shade – as representation of purity and cleanliness. [3] Nowadays, the white coat is rarely seen in hospitals, possibly due to suspicions that it may function as a vector for transmission of nosocomial infections. [4] This article addresses the validity of such concerns, by reviewing the available literature.

The vanishing white coat

Twenty years ago in the United Kingdom (UK) white coats were commonly worn by junior doctors while consultants wore suits. [5] The choice to not wear a white coat was seen as a display of autonomous, high-ranking professionalism. [6] Many older Australian nurses now recall when doctors commonly wore white coats in the hospital. Over the last decade, white coats have become a rarity in Australian hospitals. [7,8] There are many reasons why this change occurred. Table 1 outlines some common thoughts of doctors on the matter. Paediatricians and psychiatrists stopped using white coats as they thought that it created communication barriers in the doctor-patient relationship. [3] Society viewed white coats as a status symbol, [7] evoking an omnipotent disposition, which was deemed inappropriate. [6,7] In addition, it was thought white coats might be a vector for nosocomial infection. [6,9-13] With these pertinent issues, and no official policy requiring white coats, doctors gradually hung them up.

 

Reasons why doctors wear white coats	Reasons why doctors do not wear white coats
For identification purposes [8] To carry things [14] Hygiene [7,8] To protect clothes [8] To create a psychological barrier [3] Patients prefer doctors in white coats [14] Looks professional [8,14]	No one else does [8] Infection risk [5,8,14] Hot or uncomfortable [5,8,14] Interferes with the doctor-patient relationship [6,14] Lack of seniority [5]

 

Hospital policies and white coats

In 2007 the British Department of Health published guidelines for healthcare worker uniforms, that banned the white coat from hospitals in England, [15] thereby producing a passionate controversy. [4] The primary reason for the ban was to decrease health-care acquired infections, [9,12,16] which was supposedly supported by one of two Thames Valley University literature reviews. [6,13] Interestingly, these reviews stated there was no evidence to support the notion that clothing or specific uniforms, could be a noteworthy medium for the spread of infections. [6,13] On closer inspection of the British policy, however, they state: “it seems unlikely that uniforms are a significant source of cross-infection.” [15] The text goes on to support the new uniform guidelines, including the abolition of the white coat, because “the general public’s perception is that uniforms pose an infection risk when worn inside and outside clinical settings.” [6] This statement lacks evidence, as many studies show patients prefer their doctors to wear white coats [7,14,17] and the notion of patients being concerned about infection risk are uncommon. [7] It would appear that the British Department of Health made this decision for some reason other than compulsion by evidence.

Despite significant discussion and debate, the United States (US) has chosen not to follow England in banning the white coat. [3,12,18] The US has a strong tradition associated with the white coat, which may influence their reluctance to abandon them so quickly. In 1993, the ‘white coat ceremony’ was launched in the US, where graduating medical students were robed in a white coat, as the senior doctors ‘demonstrate their belief in the student’s ability to carry on the noble tradition of doctoring.’ [1] Only five years later, 93 US medical schools had adopted this practice. [1] This indicates that the white coat is a real source of pride for doctors in the US, however, tradition alone cannot dictate hospital policies. In 2009, the American Medical Association (AMA) passed a resolution to encourage the “adoption of hospital guidelines for dress codes that minimise transmission of nosocomial infections.” [19] Rather than banning white coats, [16] the AMA proposed the need for more research, noting that there was insufficient evidence to support that there was an increased risk of nosocomial infection directly related to their use. [18]

The Australian Government National Health and Medical Research Council (NHMRC) published the Australian Guidelines for the Prevention and Control of Infection in Healthcare in 2010, outlining recommendations for the implementation of infection control in all Australian hospitals, and other areas of healthcare, based on current literature. [20] It states that uniforms should be laundered daily, whether at home or at the hospital, and that the literature has not shown a necessity to ban white coats or other uniforms, as there is no evidence that they increase transmission of nosocomial infections. [20] These guidelines, also contained the article that the British Department of Health used in support of banning white coats. [6]

The evidence of white coats and nosocomial infection

There are minimal studies done trying to assess whether white coats are potential sources of infection or not. [9-12] Analysis of the limited data paints a uniform picture of the minimal possibility for white coats to spread infection.

In 1991 a study of 100 UK doctors demonstrated that no pathogenic organisms were cultured from the white coats. [10] Notably, this study also found that the level of bacterial contamination of white coats did not vary with the amount of time the coat was worn, but varied with the amount of use. [10] The definition of usage was not included in the article, although doctor-patient time is the most likely interpretation. Similarly, a study in 2000 isolated no Methicillin-resistant Staphylococcus aureus (MRSA), or other infective organisms, but still concluded that the white coat was a possible cause of infection. [11] This study stated white coats were not to be used as a substitute for personal protective equipment (PPE) and it was recommended that they should be removed before putting on plastic aprons. [11]

A recent study swabbed MRSA on 4% of the white coats of medical participants, even though it was the biggest study of its kind, there was no statistically significant difference between colonised and uncolonised coats due to the population size. [9] This study has limitations in that it did not compare contamination with clinical dress, which could potentially show there is no difference. There appeared to be a correlation with the MRSA contaminated coats and hospital-laundered coats with four out of the six coats being hospital-laundered. [9] A potential major contributing factor to the contamination of white coats could be the frequency of washing white coats. A survey in the 2009 study showed that 81% of participants had not washed their coats for more than seven days and 17% in more than 28 days. [9] Even though the 1991 study showed that usage, not time, was the determinate for bacterial load, this does not negate a high amount of usage over a long period of time. [10] Interestingly, there may be a correlation with the MRSA contaminated coats and hospital-laundered coats. [9]

In response to the British hospital uniform guidelines, a Colorado study, published in April 2011, compared the degree and rate of bacterial contamination of a traditional, infrequently-washed, long-sleeved white coat, to a newly-cleaned, short-sleeved uniform. [12] Their conclusions were unexpected, such that after eight hours of wear, there was no difference in the degree of contamination of the two. Additionally, the study concluded that there was also no difference in the extent of bacterial or MRSA contamination of the cuffs of the physicians. Consequently, the study does not discourage the wearing of long-sleeved white coats [12] and concludes that there is no evidence for their abolition due to infection control concerns.

While, all these studies indicate the potential for organisms that cause nosocomial infections to be present on white coats, [10-12] the common conclusion is there is no higher infection risk from daily-washed, white coats, than any other clinical attire. [12] It needs to be recognised there are many confounding factors in all of these studies that compare attire and nosocomial infection, hence more studies are needed to clearly establish guidelines for evidence-based practice regarding this issue. Gaining an understanding of the difference in transmission rates between specialities could assist in implementing specific infection control practices. Studies that clearly establish transmission of organism from uniform to patient, and clinical data on the frequency of such transmissions, would be beneficial in developing policy. Additionally, nationwide hospital reviews on rates of nosocomial infections, comparing the dress of the doctors and nurses would contribute to gaining a more complete understanding of the role that uniforms play in transmission of disease.

Australian hospitals and white coats

Queensland State Infection Control Guidelines published by the Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP), surprisingly had no details of recommended dress of doctors that could be found. [21] State guidelines like these, in combination with federal guidelines, influence the policies that each individual hospital in Australia creates and implements.

A small sample of hospitals across all the states and territories of Australia were canvassed to assess what the general attitudes were towards the wearing of white coats during patient contact and whether these beliefs were evidence-based. The infection control officers of each of the hospitals were contacted, by myself and the specifics of their policies attained, along with an inquiry regarding the wearing of white coats by students or staff. This data was collected verbally. Obviously there are limitations to this crude data collection it is the result of attempting to attain data not recorded.

On the whole, individual hospital policies emulated National Guidelines almost exactly, by not expelling white coats; instead encouraging them to be washed daily, like normal dress. Some hospitals had mandatory ‘bare-below-the-elbows’ and ‘no lanyard’ policies, while many hospitals did not. White coats were worn in a significant amount of Australian hospitals, usually by senior consultants and medical students (see Table 2). The general response from infection control officers regarding the wearing of white coats was negative, presumably due to the long sleeves and the knowledge that they are probably not being washed daily. [10,12]

Hospital	Policy regarding white coats	White coat worn
Townsville Hospital	No policy	An Emergency Department doctor and surgeon
Mater Hospital – Townsville	No policy	Nil known
Royal Brisbane and Prince Charles – Metro  North*	No policy	Medical students
Brisbane Princess Alexandra and Queen Elizabeth 2 – Metro South*	No policy	Medical students One consultant who requires his medical students to wear white coats
Royal Darwin Hospital	Sleeves to be rolled up	Nil known
Royal Melbourne Hospital	No policy	Nil known
Royal Prince Alfred Hospital – Sydney	No policy	Senior doctors, occasionally
Royal Hobart Hospital	No policy	Nil known
Royal Adelaide Hospital	No policy	Orthopaedics, gynaecologists and medical students
Royal Perth Hospital	Sleeves to be rolled up	Only known to be worn by one doctor
Canberra Hospital	Sleeves to be rolled up	–

This table shows white coats are not extinct in Australian hospitals and the policies in place pertaining to white coats reflect the Federal Guidelines. Policies regarding lanyards, ties and long-sleeves differed between hospitals. It is encouraging to note that Australia has not followed in the footsteps of England, regarding the abolition of white coats, as there is limited scientific evidence to support such a decision. The policies in Australia regarding white coats require daily laundering, although current literature even queries the necessity for this. [12] The negative image of white coats in Australian hospitals by the infection control officers is probably influenced by the literature that shows that white coats become contaminated. [9] The real discussion, however, is the difference in contamination of white coats and other clinical wear.

Meditations of a medical student…

My own views…

I have worn a white coat on numerous occasions, during dissections and lab experiments, but never when I am in contact with patients. According to the James Cook University School of Medicine dress policy, all medical students are to wear ‘clean, tidy and appropriate’ clinical dress. [22] No detail is included regarding sleeve length, colour or style, although social norm is a very powerful force, and the main reason that my colleagues and myself would not wear white coats is simply because no one else is wearing them. This practice is concurrent with a study on what Australian junior doctors think of white coats. [8]

Personally, I think that a white coat would be quite useful. It may even decrease nosocomial infection, as it has big pockets and could carry books and instruments, negating the need for a shoulder bag or putting items down in patient’s rooms, thus becoming a potential cross-infection risk. In regards to the effects on patients, I think the psychological impact may have some effect, but this would be different for each individual. White coats are not the cause of nosocomial infections that are rampant in our hospitals, it is the compliance of health professionals washing their hands and adhering to the evidence-based guidelines provided by infection control organisations. In Australia these guidelines give freedom to wear the white coats, so why not?

Conclusion

White coats are a symbol of the medical profession and date back to the beginnings of evidence-based medicine. Suitably, it is appropriate to let the evidence shape the policies regarding the wearing and laundering of white coats in hospitals and medical practice. There has been much debate regarding white coats as an increased risk for nosocomial infection, [3,4,12,16,18] as many studies have shown that white coats carry infectious bacteria. [9-12] But, more notably, a study published in April 2011, showed that the bacterial loads on infrequently washed white coats did not differ from newly cleaned short-sleeve shirts. [12] The reason why Britain decided to ban white coats in 2007 is a mystery. Australia has not banned white coats, although there are some practitioners who choose to wear them, but is it far from the norm. [8] A nation-wide, formal re-introduction of white coats into Australian medical schools has no opposition from infection control according to the current evidence. “…Might not the time be right to rediscover the white coats as a symbol of our purpose and pride as a profession?” [1]

Conflict of interest

None declared.

Acknowledgements

Thank you to Sonya Stopar for her assistance in editing this article.

Correspondence

S Fraser: sara.fraser@my.jcu.edu.au

References

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