American College of Physicians: Internal Medicine — Doctors for Adults ®

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Do your clothes matter?

Experts debate the importance of looking sharp in the hospital

From the August ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Charlotte Huff

Do the clothes make the doctor or, more important, improve the doctor-patient relationship?

The ever-evolving discussion on this question, seeded by studies dating back more than two decades, typically revolves around several issues, including the germ risk posed by different styles of dress, the increasingly dress-down style of today's culture, and whether patients are less likely to bond with a physician sporting a polo shirt or a bicep tattoo.

Photo by Thinkstock.

Photo by Thinkstock.



Selena Au, MD, a University of Calgary intensivist and author of a recent study on perceptions of physician appearance, believes that attire is not inconsequential, particularly for hospitalists.

“I feel that physician attire comes more into play when we're looking at a situation where the patient or family members don't necessarily have a long-standing relationship with the physician,” she said. “And they have to have this connection or ability to trust the physician within a short time period.”

Michael Edmond, MD, FACP, an infectious disease specialist at Virginia Commonwealth University (VCU), believes a physician's communication approach matters more than his or her sartorial style. “Most patients are sophisticated enough to see beyond that kind of superficial thing,” said Dr. Edmond, a professor of internal medicine at VCU Medical Center in Richmond.

The attire discussion was reignited in March by the publication of Dr. Au's study in JAMA Internal Medicine. The survey of 337 family members of patients in three Canadian intensive care units (ICUs) found that 77% chose an easy-to-read nametag and 66% chose neat grooming as important to their first impression of an ICU physician. Wearing a white coat or covering up tattoos wasn't ranked as high, with 32% and 30% giving it importance.

But when the family members were shown photos of physicians in different kinds of clothing, the doctor in the white coat was rated as the best physician overall, by 52%. Doctors in scrubs ranked next at 24%, followed by those wearing a suit (13%) or casual attire (11%).

Style matters?

Changes in ideas about appropriate dress for physicians likely reflect shifting cultural standards outside the doctor's lounge. A 1980s snapshot of patient preferences, published in 1987 in the Journal of the American Medical Association, found that 34% preferred their female doctor to wear a dress or a skirt. (Two-thirds of the 200 patients surveyed also favored a white coat.)

“I think life in general has become more casual,” said Matt Bianchi, MD, PhD, chief of the division of sleep medicine at Massachusetts General Hospital in Boston. When Dr. Bianchi was a resident at Mass General and Brigham and Women's hospitals in the mid-2000s, there was a bit of a backlash by some senior faculty members who felt that the physicians in training were “getting sloppy” by dropping the white coat and tie, he said.

Dr. Bianchi decided to analyze the available data on the subject. In a commentary piece, published in 2008 in the Journal of General Internal Medicine, he argued that regardless of studies' findings, researchers tend to interpret the results to reflect their preference for more conservative physician dress.

Some patients might prefer the “authority aspect” of a white lab coat, Dr. Bianchi said in an interview., but for others it might be a turnoff. “We can't be clairvoyant in anticipating over the course of the day...which patients need us to look a certain way in order to maximize trust,” he said.

At Oregon Health & Science University, white coats are common among the clinical hospitalists, unless they're working an overnight shift, in which case scrubs are considered acceptable, said Renee Rutledge, MD, ACP Member, a clinical and teaching hospitalist at the Portland-based facility. Hospitalists wearing white coats most of the time makes sense, she said: “I'm not in the OR. I'm not a surgeon.”

Appearance also can help build trust with some patients, particularly if the physician is relatively young, said Dr. Rutledge, who is 33. She wears a mix of skirts and slacks paired with blouses or fitted sweaters beneath her white coat. Her goal is to align her professional dress with her professional communication style.

“There is no second chance to make a first impression,” she said. “I can win them back later with my perceived skills. But I don't want to be swimming upstream against the way that they visually perceive me.”

Germ transmission

Patients' perceptions change, however, with a bit of education about the health impacts of physician attire, said Dr. Edmond. He cited one study involving a British hospital, published in 2008 in the Journal of Hospital Infection, which found that patients' views of their surgeons' clothes changed after a short educational session describing how sleeve cuffs and ties can transport germs.

Before the session, 24% of patients preferred scrubs and 52% preferred smart street attire (a more traditional mix of coat, long sleeves and tie); the remainder had no preference. Afterward, 62% voted for scrubs and 22% for smart attire.

In 2009, Virginia Commonwealth's infection control committee recommended that doctors treating hospitalized patients avoid the white coat and a tie, and keep their arms bare below the elbows. It's a recommendation only, as there isn't sufficient data to support a mandate, Dr. Edmond said.

Increasingly, more VCU Medical Center doctors and nurses are donning scrubs, he said. In 2013, a new infection control strategy was instituted along with coat hooks in the work rooms of doctors and nurses, as well. “Hang It Up!” advises a nearby poster, encouraging clinicians to shed their white coat or jacket before entering a patient room.

Rolling up the sleeves of a white coat or jacket also is helpful, Dr. Edmond said. But rolled sleeves don't eliminate the germ transmission risk from other parts of the coat.

Indeed, one-third of doctors (30%) get their white coats cleaned every two weeks, according to an unpublished 2008 survey of 143 VCU physicians conducted by Dr. Edmond and a colleague. An additional 32% of physicians waited at least a month between laundry trips. “I don't think it's different anywhere else,” Dr. Edmond said. Dr. Rutledge noted that she rotates among the three white coats she owns, laundering them every one to two weeks.

In addition to patient perceptions, physicians often argue for white coats because they provide useful storage for equipment and notes. For females, skirts and dresses often have scant pockets, Dr. Rutledge said. Carrying a purse that might be set down in a patient's room is not a hygienic option, she said.

Dr. Edmond, who prefers scrubs, wears cargo pants with pockets for storage. For added warmth during colder months, he adds a vest on top. Close-fitting clothes are not as likely to brush against the patient as a tie or more loose-fitting coat, he said. (If wearing a tie is important to you or your hospital, tuck it in when examining a patient, he recommended.)

When Dr. Bianchi published his commentary, he described his attire as no white coat or tie, black hoops in both ears and some tattoos. These days, he's assumed a more administrative role and made modifications. He's often in khakis and long sleeves, with very occasionally a tie. The black hoops remain. “I still to this day do not own a white coat,” he said.

Another argument against white coats is that they are increasingly less the mark of a doctor, as myriad other hospital staffers wear lab-style coats. “It's really not an identifying feature in the hospital at all,” Dr. Bianchi said.

Thus, it's never been more important for doctors and other clinicians to introduce themselves and not rely on clothing or a nametag to do the work, said Dr. Au. She introduces herself as Dr. Selena Au, because it's the most formal and inclusive description of her name and title, she said.

“A solid introduction that clearly identifies oneself is important for patients and family in a new and stressful environment,” Dr. Au said. “They appreciate it.”

Charlotte Huff is a freelance writer in Fort Worth, Texas.

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