What to Wear: Clinical Attire in O&P

Physicians “must have a clean appearance, and wear good clothes” and “dress decorous and simple, not overelaborated, but aiming rather at good repute….”

Hippocrates

Arnold Gold, MD, professor of Clinical Neurology and professor of Clinical Pediatrics at the Columbia University College of Physicians and Surgeons was an advocate for compassion and human connection in medical care. In 1988, he and his wife established the Arnold P. Gold Foundation, which is dedicated to “keeping healthcare human.”¹ Believing that the practice of medical students taking the Hippocratic Oath “at the end of their medical training occurred four years too late,” he implemented the first White Coat Ceremony at the institution in 1993.² This ceremony is now common in medical schools and some O&P schools across North America as a way to “welcome students to healthcare practice and to elevate the value of humanism as the core of healthcare. It provides a powerful emphasis on compassion in combination with scientific excellence.”² While the structure of the ceremony varies across institutions, “the most important element of the ceremony is the oath that students take in front of family members, school leadership, and their peers to acknowledge their central obligation of caring for the patient.”² In many aspects of society, clothing choice represents not only practical considerations related to job performance, but also (and often more so) expectations regarding the expertise and responsibilities of the wearer.

Historical Perspectives

Since the end of the 19th century, the color white has been a common feature of a physician’s attire and the white lab coat has become a symbol of the professional responsibility physicians have toward patients. Prior to that time, it was common for physicians to wear black as a symbol of the gravity and formality of the interaction between the physician and patient. The reality that “until the late 19th century, seeking medical advice was usually a last resort and frequently a precursor to death” added to the seriousness of physician/patient interactions.³ Black clothing was also the choice of clergymen, as a way to indicate “the solemn nature of their role in encounters with parishioners.”³ Health conditions that required medical attention were especially serious since “until the last third of the 1800s, an encounter with a physician rarely benefited the patient.”³ Anyone sick enough to require a visit from a physician likely had few other options, and medical interventions offered little to resolve health conditions and fend off the inevitable. Scientific advancements during the late 1800s and early 1900s, including the understanding of germ theory and principles of antisepsis, improved the outcomes of medical and surgical interventions and resulted in an emphasis on cleanliness. This most likely influenced the change in attire for doctors and nurses. “At the end of the 19th and the beginning of the 20th centuries, when medicine became the truly scientific enterprise we now know, the ‘whiteness’ or ‘pureness’ of medicine became reflected in the garb of physicians and, interestingly, nurses.”³ Individuals seeking medical care could view the white coat as “a symbol of the caring and hope they expect to receive from their physicians” as opposed to the lack of hope that had accompanied visits from more darkly attired physicians in earlier times.³ Over time, the distinctive attire of different medical professionals also helped to delineate professional roles within the healthcare team, and helped patients distinguish between providers.

A Systematic Review

In 2015, researchers in Michigan published the results of a systematic review “to examine the influence of physician attire on patient perceptions including trust, satisfaction, and confidence.”⁴ They were interested in “how physician specialty, context of care and geographic locale, and patient factors such as age, education, or gender may influence findings” since these factors had not been considered in many previous studies.⁴ They also pointed to conflicting results regarding patient perceptions of physician attire in two other reviews (performed in 2008 and 2014) as a motivation for their review. They hypothesized that formal attire would be preferred by patients and that “patients receiving care in acute-based or procedure-based settings are less likely to be influenced by attire.”⁴ Studies that included only pediatric and psychiatric patients were excluded.⁴

A variety of research methods were used in the 30 reviewed studies. In 19 of the studies researchers used a picture-based survey, and other studies involved surveying patients in the context of a clinical encounter. The number of participants in the studies ranged from 11 to 1,506, and approximately two-thirds were female. Both hypotheses made by the researchers were corroborated. “When patients voiced a preference or were influenced by physician attire, formal attire was almost always preferred followed closely by white coats either with or without formal attire…. Notably, patient age was often predictive of attire preference with patients older than 40 years of age uniformly preferring formal attire compared to younger patients in seven studies. Conversely, younger patients often felt that scrubs were perfectly appropriate or preferred over formal attire.”⁴ There were differences related to the geographical location of the study. Ten of the studies were completed in the United States, and only four of those “reported that attire influenced patient perceptions regarding their physician.”⁴ However, participants in studies conducted in Canada, the United Kingdom, Scotland, Ireland, other European nations, Australia, New Zealand, the Middle East, and Brazil preferred that physicians wear white coats.⁴

The reviewers found an interesting difference between preferences based on whether patients were questioned following a clinical encounter: “Clear preferences regarding physician attire were reported in 16 of 18 studies where patients received either written descriptions…or pictures of physician attire without a corresponding clinical interaction with a physician.”⁴ The most common preference in these studies was “formal attire either with or without a white coat.”⁴ However, in nine out of 12 studies reporting on patient preference after an encounter with a physician, “patients did not voice any attire preference…suggesting that attire may be less likely to influence patients in the context of receiving care.”⁴ The authors concluded that “‘tailored’ approaches to physician attire that take into account patient, provider, and contextual factors appear necessary.”⁴ Patient preference is not the only factor to consider. The authors stated that “while many patients did not report an attire preference when directly surveyed, several of our included studies found that images of [physicians] dressed in white coats or formal suits were more often associated with perceptions of trust and confidence even if patients also expressed no specific preferences regarding attire.”⁴

Gender Differences

Cultural expectations regarding clothing can create additional challenges for women in medical professions. Researchers at the Johns Hopkins and University of Maryland Schools of Medicine recently reported on a study designed to “characterize public perceptions of casual physician attire” and explore how physician gender can affect role identification and the impressions patients have of physicians.⁵ As background, Xun et al. reported that prior research demonstrating that “a female physician’s attire was associated with trust and confidence building more often than was a male physician’s attire. Female physicians are also held to higher sartorial standards….”⁵ In another study, “73 percent of patients voted that business attire without a white coat was inappropriate for female physicians compared with 24 percent for male physicians.”⁵ In Xun et al.’s study, patients were shown photographs of a male or female model “wearing several permutations of nonbranded healthcare attire consisting of inner wear (business attire or scrubs) with or without outerwear (long white coat, fleece jacket, or softshell jacket)….”⁵ The patients rated each model’s professionalism and identified the model’s profession as “physician, surgeon, nurse, medical technician, or physician assistant.”⁵

Male models were perceived as more professional than female models who were wearing the same attire, whether the attire was formal, scrubs, or included a white coat. When wearing a white coat, both male and female models were perceived most frequently as physicians, but “the male model was more likely to be identified as a physician than was the female model….”⁵ When wearing hospital scrubs, both male and female models “were most frequently perceived as surgeons,” but more patients perceived the male models in that role than the female models.⁵ “The female model in scrubs was more often perceived as a nurse…than was the male model.”⁵ Even wearing the most formal attire and a white coat did not resolve differences in patient perception of the models’ roles. Female models were more likely than males “to be identified as a medical technician…or a physician assistant…” when wearing “a white coat with business inner wear.”⁵ The situation is not that women need to dress more formally to be given the same recognition as men in the same roles, but that even when they dress the most formally, they may not be viewed as positively. 

Reflections

A common dress code for male practitioners when I completed residency included a dress shirt and tie. (During a visit to a rehabilitation unit a physical therapist made this observation about O&P clinicians: “You O&P guys dress like businessmen.”) Standards regarding attire have changed in the decades since then, and a variety of clothing options are considered appropriate for clinicians. Images and portrayals of O&P clinicians in the literature, websites, and social media accounts of our professional organizations include a diversity of attire. White coats, scrubs, formal, and business casual attire are all common, although it seems that more students than certified clinicians are featured wearing white coats. This accurately represents the wide range of clothing common within the profession.

Given that at the time of Xun’s study there were more than twice as many male physicians as female physicians and almost ten times as many female nurses as male nurses, patient assumptions about the role of medical professionals based only on their gender are understandable.⁵ Despite more female than male students currently graduating from O&P programs, it will take some time for the expectations of patients and colleagues to adapt to this new reality. Female O&P clinicians may experience the same biases regarding perceptions of their attire and professional attributes as female physicians, and all of us should be aware of the additional challenges this creates. In addition to creating confusion on the part of patients, failure to identify professional roles may make it more difficult for female practitioners to develop rapport with patients. It is advisable to follow the advice of Xun et al., who recommend that “all physicians, regardless of attire, should clarify their roles during introduction to patients and all team members.”⁵ It is disappointing to me, though no longer surprising, to witness how frequently this common courtesy and professional practice is neglected in medical encounters.

It is important to remember that “cleanliness, scientific achievement, and professional responsibility” are more important than the white coat that symbolizes those values.⁵ According to Petrelli, “Regardless of attire, being well-groomed in appearance and displaying visible nametags were viewed favorably by patients when this question was specifically asked in the included studies,” and “patients who received clinical care were less likely to voice preference for any type attire than patients that did not, perhaps exemplifying the importance of interaction over appearance.”⁴ Practitioners can build rapport and perform effectively regardless of attire but should be aware of the different impressions clothing choices may make on their patients.

There is value in marking significant personal and professional milestones, and the donning of a white coat should signify an important transition into the role of a compassionate provider of O&P services. Students achieving this milestone should recognize that developing clinical skills requires an ongoing commitment that is more important than their clothing choices. Being worthy of the white coat is more important than wearing one.

 John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.

 References

1. https://www.gold-foundation.org/about-us/
2. https://www.gold-foundation.org/programs/white-coat-ceremony/background-and-significance
3. Hochberg, M. S. 2007. The doctor’s white coat: An historical perspective. AMA Journal of Ethics 9(4): 310-14.
4. Petrilli, C. M., M. Mack, J. Janowitz Petrilli, A. Hickner, S. Saint, and V. Chopra. 2015. Understanding the role of physician attire on patient perceptions: A systematic review of the literature—targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ open 5(1): e006578.
5. Xun, H., J. Chen, A. H. Sun, H. E. Jenny, F. Liang, and J. P. Steinberg. 2021. Public perceptions of physician attire and professionalism in the US. JAMA Network Open 4(7): e2117779-e2117779.