Your mom probably told you to dress for success. If you wanted to be taken seriously, then dress the part.

For physicians, that key accessory has traditionally been the lab coat. On the other hand, if white coats produce hypertension, is it time to send a new line of physician attire down the runway? (There is a lab coat adorned with the markings of a cow; has that one been tested for its effect on blood pressure?)

Given the lack of a dress code in some of today’s leading businesses, with casual Friday just a little more upscale than spring break, should medical professionals dress down a little?

No one will confuse JAMA Internal Medicine for Vogue or GQ, but recently the medical journal has taken to addressing proper physician fashion, including the most clinically effective couture and the impact of personal details, like piercings and tattoos.

ICU Dressing Down – or Not?

Given that attire is easily modified, one new study sought to determine the best approach in the toughest setting. Patient-physician interactions in the intensive care unit (ICU) differ from other health care settings. Often, ICU physicians don't have a preexisting long-term relationship with their patients, and, given the gravity of the immediate situation, trust needs to be established quickly.

Add to that the fact that the severity of patient illness frequently results in the active participation of family as surrogate decision makers, the whole patient-physician relationship gets complicated in the ICU.

Selena Au, MD, Farah Khandwala, MSc, and Henry T. Stelfox, MD, PhD, of the University of Calgary, Alberta, conducted a survey of three ICUs to examine patient family perceptions and preferences.¹ Participants were asked to rate the importance of 10 physician-related factors (age, sex, race, neat grooming, facial piercings, visible tattoos, professional dress, white coat, visible name tag, and overall first impression).

The survey was offered to 501 family members, 337 (67 percent) of whom agreed to participate. A majority of respondents indicated that it was important for physicians to be neatly groomed, professionally dressed, and (the #1 item) wear a visible name tag, but not necessarily sport a white coat. (Only 32 percent of respondents reported an explicit preference for the white coat.)

Participants were also shown photographs depicting clothing that varied in formality (with scrubs or jeans being less formal and a white coat or business suit being more formal) and specificity (with scrubs or white coats being specific to health professionals and jeans or business attire being not specific).

Despite their self-reported preferences regarding specific variables, when patients' families selected their preferred physician from a panel of photographs, respondents strongly favored physicians wearing traditional attire complete with white coat. The central casting look was associated with perceptions of knowledge, honesty and providing best overall care. Physicians wearing scrubs were a second choice among participants and were perceived to be caring and competent to perform a lifesaving procedure.

Let’s face it, despite a culture obsessed with going "casj" (yes, that's the spelling of the slang word for casual), the authors noted that white coat and scrubs share the commonality of being a uniform, which may help patients and families identify their health care providers. They wrote, "Given the importance of effective communication in the ICU, physicians may want to consider that their attire could influence family rapport, trust, and confidence."

Cravat…uh, Caveat Ahead

In an accompanying editorial,² Mary Catherine Beach, MD, MPH, April Fitzgerald, MD, and Somnath Saha, MD, MPH, noted that without the investigator’s photograph ratings, it might be assumed that "professional dress" means something more formal (e.g., a suit or white coat), yet the picture analysis suggests that "professional dress" really means something that specifically identifies the person as a health professional, since scrubs (less formal, more identifying) outperformed the business suit (more formal, less identifying) on all measures.

Also, the study intentionally used images of individuals that varied by sex and race. Did these characteristics influence participant choices more than attire? Using a similar study design, Rehman and colleagues have previously reported that patients considered attire more important when rating female physicians than when rating male physicians.³

The authors wrote in their commentary, "Because patients and families are often in a position of vulnerability, especially in an ICU setting, with little ability to choose between physicians, it is worth considering and honoring their preferences in the interest of enhancing comfort and trust, even if it compromises physicians' own comfort and convenience to do so."

Big caveat: patient preference cannot be the only consideration. They noted studies have suggested that white coats may transmit nosocomial infections. This has prompted policies prohibiting physicians from wearing white coats — and other infrequently cleaned apparel, such as neckties and watches — in parts of the United Kingdom. Although controversial, they noted that if the white coat is shown to be less safe for patients, "we should find other ways to honor patient preferences for the recognizability of physicians."

A Piercing Report

In a short but memorable correspondence in the same issue,⁴ Rebecca Lesto Shunk, MD, of the San Francisco VA Medical Center, discussed sitting in on a morning report while interviewing for a junior faculty position "at a very prestigious academic medical center." The case details have faded but not the details of the chief resident leading the report.

"She was wearing pants and a short top that allowed a belly button ring to be prominently displayed." Dr. Shunk wrote, "I could not concentrate and began to doubt the caliber of the program."

Dr. Shunk may find encouragement in the other two articles reported above. And a chief resident at a prestigious center may find evidence lab coats look highly professional – and many can be fully buttoned.

References

1. Au S, Khandwala F, Stelfox HT. Physician attire in the intensive care unit and patient family perceptions of physician professional characteristics. JAMA Intern Med 2013. Online February 18 before print. http://archinte.jamanetwork.com/article.aspx?articleid=1653992
2. Beach MC, Fitzgerald A, Saha S. White coat hype: Branding physicians with professional attire. JAMA Intern Med 2013. Online February 18 before print. http://archinte.jamanetwork.com/article.aspx?articleid=1653997
3. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med 2005;118:1279-86.
4. Shunk RL. Professionalism – A piercing dilemma. JAMA Intern Med 2013. Online February 18 before print. http://archinte.jamanetwork.com/article.aspx?articleid=1653993

Keywords: Physicians, Intensive Care Units, Physician-Patient Relations, Trust, Patient Preference, Hypertension

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