Unlocking doctors’ dress codes

Covid-19 has moved the goalposts significantly in the sartorial stakes

Dress codes in medicine have long been considered important. Hippocrates advised doctors to be “clean in person” and “well dressed”. Mind you, he also recommended that they be plump and that they cover themselves with “sweet-smelling unguents”. Covid-19 has moved the goalposts significantly in the sartorial stakes: Not seeing a patient in person has led to a relaxation in the usual ground rules. Patients, too, have gone with the flow – with some appearing on screen in various stages of undress.

Scrubs have become ubiquitous in hospitals. Usually the acceptable garb for surgeons, anaesthetists and emergency physicians, the need for all doctors to change in and out of PPE on an ongoing basis has seen scrubs become the norm on wards too. Traditionally, how we dress has been about creating a good first impression and projecting the more professional, conservative image often associated with medicine.

A 2002 Australian study of 12 male general physicians and 1,680 patients in a teaching hospital took place over a seven-month period. The 12 doctors sequentially removed, changed or added one piece of clothing during this time.
Firstly, they shed their white coat, then took off their ties, before changing from formal trousers to jeans. The next sequence involved wearing Hawaiian shirts, followed by highlighting their hair before finally donning a nose ring.
Formal attire promoted the greatest patient confidence and trust.

The item that triggered the most dramatic loss of confidence was the nose ring, while wearing a formal shirt and trousers was the minimum required to inspire a reasonable amount of confidence by patients in their physicians.

But that was then. Ties are now considered an infection hazard, while many hospitals have ditched the traditional white coat for staff and students. In a 2015 review of patient preferences for doctors’ attire carried out by researchers at the University of Michigan, three key themes emerged that suggest important variations in what patients may prefer their doctors to wear.

First, studies involving older patients or those from Europe or Asia all reported higher satisfaction when physicians wore formal attire. vSecond, in emergency, surgical or intensive care settings, scrubs were not only preferred by patients, but also more often equated with professionalism. This makes sense, as in these more “hands-on”, procedure-oriented settings, formal suits, shirts and ties clearly seem out of place. Finally, in doctors’ offices and outpatient clinics, scrubs were viewed unfavourably and often resulted in negative impressions.

The same researchers carried out a 2018 study in which just over half of the 4,062 patients surveyed in the clinics and hospitals of 10 major medical centres said that what physicians wear is important to them – and more than one-third said that what a doctor wears influences their satisfaction with their care. The obvious question then is: Should we cater to others’ – patients’ or colleagues’ – unconscious biases? It seems that what we wear to work is evidence to many of our training and (perhaps questionably) our clinical competency.

However, balanced against potential patient bias or discomfort is an individual’s prerogative to express themselves. So says bioethicist Mary Catherine Beach, MD, MPH, a Professor of Medicine at Johns Hopkins University School of Medicine, in the context of the acceptability of visible tattoos on doctors. Tattoos with offensive words or symbols are inappropriate and piercings that are an expression of a religious, ethnic, or cultural tradition should be respected, she says. The pendulum is swinging toward greater acceptance, Beach notes. “As things become more normative, they become less distracting.”

In a sign of the times, a 2018 US study into doctors’ appearance found the presence of visible body art seems to have no discernible impact on what patients think of their doctor’s professionalism or competence. US researchers quizzed nearly 1,000 emergency care adult patients in an urban trauma centre in Pennsylvania about their doctors’ appearance after they had had a consultation.

Patients were specifically asked what they thought of their physician’s competence, professionalism, caring attitude, approachability, trustworthiness, and reliability. The patients were told the survey aimed to find out how the centre could better provide courteous and competent medical care, with the aim of improving their experience, rather than what they thought of doctors with visible tattoos and piercings.

Interestingly patients rated all the studied qualities highly more than 75 per cent of the time, irrespective of whether or not they were treated by a doctor wearing visible body art. Clearly, the times they are a changing. It’s too early to conclude how virtual consults will change attitudes to physician dress and body art; but it seems unlikely to reverse a definite trend towards a general relaxation in the “how we look” code.