People have argued over what to wear for millennia. First impressions matter, and fashion has long been a highly visible signifier of a person’s place within the community. In the hierarchal world of medicine, clothing…
People have argued over what to wear for millennia. First impressions matter, and fashion has long been a highly visible signifier of a person’s place within the community. In the hierarchal world of medicine, clothing can be an important signal to patients and other health care providers of everything from authority to cleanliness, and the white laboratory coat typically signifies the attainment of the highest rung on that ladder. In fact, medical schools around the country host White Coat Ceremonies in which students are bestowed a white coat to signify their transition from ordinary citizen to doctor.
But the white coat wasn’t always the symbol of the physician. In the 17th century, during outbreaks of plague, doctors wore full-length overcoats, wide-brimmed hats, gloves and a beak-shaped mask filled with lavender or other pungent herbs in the belief that this protective gear would prevent contraction of the deadly disease.
As understanding grew about how infections travel, doctors ditched the frightening masks and donned black, formal garb, similar to a tuxedo. It was believed that wearing black — like priests wore — signaled the solemnity of the task of caring for the ill. However, an article in the AMA Journal of Ethics noted that “until the last third of the 1800s, an encounter with a physician rarely benefited the patient. In fact, up to that point, virtually all of ‘medicine’ entailed many worthless cures and much quackery.”
In an effort to shift this perception, doctors ditched the black clothing and adopted white coats, says Dr. Michael B. Edmond, an infectious disease specialist at the University of Iowa Hospitals and Clinics in Iowa City. “Initially the white coats were worn only in the operating room. Then in the early 1900s, physicians started wearing them outside the operating room because at that point in time, medicine wasn’t considered to be scientific. The profession was viewed negatively by the public, so the concept was doctors would wear white coats because it reinforced the notion that they were scientists.” From there, the tradition grew, and now when we think of a doctor, an image of a person wearing a white coat and carrying a stethoscope comes immediately to mind.
However, this long-held vision of how a doctor should look — a middle-aged white man in a long, starched white laboratory coat over a dress shirt, tie and slacks — is changing yet again. As diversity in medicine increases along with a push to reduce transmission of infectious agents, what the doctor wears is becoming less formal, but perhaps safer.
In 2008, the National Health Service in the United Kingdom adopted a ” bare below the elbow” policy in which doctors and other health care workers ditched the lab coat and long sleeves in favor of scrubs — those simple and comfortable, brightly-colored, short-sleeved tops and bottoms that are ubiquitous among nurses and residents at hospitals.
The idea, Edmond says, was to reduce the chances that a health care worker’s clothing would come into contact with patients’ skin and other surfaces that may host bacteria and other infectious agents. “We know that all people have bacteria on their skin, and in the hospital setting in particular, these could be multi-drug resistant organisms. We also know that the environment around the patient in the hospital is also contaminated with organisms. We have good evidence that clothing of health care workers becomes contaminated as they work,” he adds, noting that as health care providers move through the day and interact with patients, it’s easy to pick up bacteria that could potentially be transmitted on to other patients. “We have some experimental evidence that organisms can be transmitted from clothing to the patients.”
Although Edmond says there’s not much evidence that removing sleeves will greatly reduce transmission of infection, it seems like so much common sense that sleeves and cuffs could potentially be a problem, especially if those sleeves and cuffs are not washed daily. “Your mother would tell you that if you wore the same article of clothing every day to work, that’s probably an infection problem. Or something that looks grossly dirty, which many lab coats do, that’s a problem.” He says this sense is supported by “studies that that show people don’t frequently wash their white coats,” with one showing that “on average, people washed their white coats about every two weeks.” In one study, 17 percent of medical residents reported that they had never washed their white coat. “So you’re wearing this thing every day in an environment that’s heavily contaminated with bacteria and you’re not washing it.”
Neckties pose a similar threat. “Neckties just aren’t washed, so you’re wearing that same article of clothing repeatedly. You have no way of decontaminating it, and that’s why the whole concept of bare below the elbows came into effect. Because whether it’s a lab coat or a shirt, the cuff is going to get contaminated,” and when moving from one patient to another, it’s impractical to change or wash shirts. Bare skin is much easier to wash thoroughly before moving on to the next person.
However, there is some debate about just how big a threat sleeves are in transmitting infectious agents. Dr. Vineet Chopra, chief of the division of hospital medicine and associate professor of medicine at the University of Michigan Hospitals — Michigan Medicine and VA Ann Arbor Health System, has also studied doctor attire and says while “there is a theoretical risk that infections could be transmitted by white coats,” the risk is small, especially when paired with appropriate hygiene and hand washing.
“Studies have isolated bacterial pathogens from white coats, ties, and it’s for these reasons that nations like the UK have a ‘bare below the elbows’ policy. However, it is also true that if you simply swab hands of physicians, you can isolate bacteria. In fact, bacteria are everywhere. So simply finding bacteria does not equate to infection risk. What is most important to prevent infection is the basics of safe practice: washing hands before and after patient contact, making sure we adhere to best infection control practices, such as wearing gowns and gloves when appropriate. A little bit of hygiene is all that it takes,” he says.
Nevertheless, since the NHS’ bare below the elbows policy was enacted, the number of hospital infections in the UK has declined. Still, Edmond says this result can’t be attributed specifically to the policy. “Like many things with infection control, we hardly ever do one intervention. [NHS hospitals in the UK] did several things to try to reduce their infection rates and that was one of them. But they did see a reduction in infectious disease rates as a result.”
So the debate continues about the hygienic reasons for removing sleeves, but there are still other implications to how your doctor dresses. Even Shakespeare wrote, “for the apparel oft proclaims the man,” which could be translated into our more common version: The clothes make the man. Or do they?
They might, according to a recent study led by researchers at the University of Michigan. In the largest-ever study of patient preferences of doctors’ attire, Chopra and his teamfound that for many patients, what physicians wear is important to them and may influence how satisfied they feel with the care they receive.
The study participants looked at pictures of physicians in seven forms of attire and rated their appearance on how comfortable that attire made the patient feel and how knowledgeable, trustworthy, caring and approachable the clothing made the doctor seem. The traditional white coat over formal attire was ranked highest and tended to be more popular among patients over age 65. Scrubs with a white coat ranked second, and formal attire without a white coat ranked third.
Chopra says the idea to investigate whether physician attire has any impact on patient care stemmed from an offhand comment by a doctor in training. “I had an intern who was always sharply dressed on wards — cuff links, a lovely shirt and tie and a crisp white coat. Most interns don’t dress this way. I asked him what prompts him to dress so formally when caring for patients and his response was, ‘I believe patients prefer it.’ We looked and found limited evidence and wondered — do the clothes make the doctor? So we designed this large-scale study to see if we could find answers.”
And they did get some answers. “Our study shows that the majority of patients feel that how their doctor dresses affects their satisfaction with care,” Chopra says. “We didn’t ask for outcomes, specifically and — as this was largely a survey-based study using pictures — that would be hard to assess. But the key point is this: First impressions matter. True in fields outside of medicine — and from what we have found — true in medicine as well.”
Humans have certain expectations for how other humans will look, based on what we know about their role and place in society. “All professionals have uniforms — think the armed forces, police, airline pilots. It aids with recognition but also gives you a sense that this person is somehow appointed to be able to do what they do,” Chopra says. “They’ve got the right training, background, skills and certifications. Uniforms are symbolic of the profession.” For the past 120 years or so, “that uniform for physicians has been the white coat.”
When the doctor doesn’t conform to that preconceived notion, it may alter the way the patient perceives the care. “I think that all humans have first impressions of other humans, so probably how a physician is dressed might have some impact on first impressions,” Edmond says. “But I think that most patients are sophisticated enough that they see through that pretty quickly” and are able to separate what the clothes signal from how the doctor behaves. “I think how well you’re dressed probably doesn’t matter if you’re taking care of your patient well.”
As Edmond notes, studies about clothing and perception tend to isolate that factor from the whole constellation of reasons that may go into selecting a specific doctor. “Certainly, you don’t pick your doctor on that one particular aspect out of context with everything else.” And he argues that regardless of what the doctor is wearing, attire should take a back seat to more care-centric concerns. “I’m much more interested in how the doctor treats the patients. And having been a doctor for 30 years, I think what patients really want from you is that when you’re with them, you are listening to them intently. And then when you’re not with them, they’d like a way to easily get ahold of you. If you pay attention, I think most of this other superficial stuff really melts away.”
For his part, when meeting patients, Chopra says he prefers to wear “formal attire. To me, this means a shirt, tie, formal trousers and shoes. I always wear a white coat with my ID and tags clearly visible so that patients know who I am, my degrees and affiliation,” which are written on his coat. He says he’s found this uniform to be “comfortable, professional and helpful when I interact with patients. Quite simply put, it makes me feel like the professional I am. And I believe it makes patient feel the same way as well.”
When he’s at work, Edmond wears scrubs and enacts his own bare below the elbows policy, which means no jewelry or wrist watches, as they can also harbor potentially infectious bacteria. He says the concept of professionalism in medicine — or dressing to match the part of the doctor — misses the point of caring for patients. “That’s about doctors. It’s not about patients. Patients aren’t complaining about [what doctors wear]. It’s doctors complaining about other doctors.”
He says if we could replace that professionalism argument with humanism, or putting patients and their care ahead of concerns about being perceived as a professional, “that kind of stuff melts away. If you look at how doctors dress through the lens of humanism, then what it tells us is that you should be clean, comfortable, functional and safe. Whether it means you have the white coat on or not, it doesn’t really matter when you go back to those four things.” As he notes, the doctor is still a doctor whether he or she is wearing a white coat or not.