Sphere 1 seems at odds with the pragmatic spirit of Sphere 2, and with the self-lifting spirit of Sphere 3. Of course, each has its merits, and aside from extreme cases, none seems particularly unreasonable. Where does the issue of physician dress code land? This topic pops up every now and again in local department “rules,” as well as media stories, and even in the medical literature. The discussions span practical, traditional, and even sometimes patient safety arenas like infection being potentially spread by coats and ties. Perhaps the only moment of solidarity comes in the form of White Coat Ceremonies at the heart of most medical school curricula, and all of its associated symbolism.
However, even in my own training years across medical school and residency, the proportion of white-coat-wearing people had changed over time. MDs might opt against the coat, while other practitioners might don a very similar or identical looking coat. The media doesn’t seem to pay much attention to physician garb, except it seems in sporadic re-discovery of the discussions involving infection risk with long sleeves, neck ties, jewelry, and so forth.
Sometimes the question of physician attire, with respect to infection risk, even takes on an “evidence-based medicine” air, though our typical randomized double-blind clinical trial design would be tricky to implement when it comes to clothing. Even if we tried to brainstorm at the whiteboard, we might quickly enter the rabbit hole of stratifying even a naturalistic trial to span all possible combinations of clothing, jewelry, and even medical accoutrements used in examinations. If you are already seeing the stage set for a tempting satirical crossover trial, well, there is nothing new under the sun (I’m not making this up: see Nair et al 2002).
But seriously, there is a literature out there attempting to study physician dress and patient response to it. Delving into this area has all the anticipatory excitement of finding the Cracker Jack toy: you know it’s not going to be that great, but you can’t help but look. Curiosity got a hold of me, I’ll admit, when I was a resident, and eventually I felt compelled to write a critique on the prevailing dress code literature in medicine (Bianchi 2008).
So it turns out that physicians wearing white coats is (a) fairly new and (b) not restricted to physicians – two simple points that make the “tradition” and “identification” arguments a bit shaky for a pro-dress-code stance. Even if the original Hippocratic oath itself contained attire recommendations, multiple recent commentaries outline numerous “revisions” to the language to fit what current society thinks is reasonable. A medical historian, Dr Markel (2004) wrote an elegant piece in the New England Journal of Medicine, and conveniently it was published the same year as my medical school graduation. Among other pearls, we learn that surgery itself, now obviously central to the practice of medicine, was viewed quite oppositely in the Apollo-swearing oath of antiquity which explicitly prohibited it!
Perhaps the bottom line is that patient trust is critical, and what might seem superficially about outward appearances is really about the big picture of how trust is earned in the physician-patient relationship, which for better or for worse, may involve attire. Even when taking this perspective, it is curious that the literature adds an interesting twist: it turns out perception can actually supersede reality in this interaction. In a now-20-year old study (Pronchik et al 1998), patients were asked about their physician experience after the fact, and it turned out their memory revealed improved formality of clothing worn by doctors who with whom they had positive interactions.
Perhaps we physicians can thus take some solace in simply being the best doctor that we can be, and each patient’s memory will dress us in retrospect as it sees fit.
Contributed by: Matt Bianchi MD PhD
A version of this blog was originally posted on HorseAndZebra (no longer active), in 2011
Markel H. “I swear by Apollo”– on taking the Hippocratic oath. N Engl J Med. 2004 May 13;350(20):2026-9.
Nair BR, Attia JR, Mears SR, Hitchcock KI. Evidence-based physicians’ dressing: a crossover trial. Med J Aust. 2002;177(11–12):681–2.
Pronchik DJ, Sexton JD, Melanson SW, Patterson JW, Heller MB. Does wearing a necktie influence patient perceptions of emergency department care? J Emerg Med. 1998;16(4):541–3.
Bianchi MT. Desiderata or dogma: what the evidence reveals about physician attire.J Gen Intern Med. 2008 May;23(5):641-3.