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Professional Attire,” Tive Attributes Mentioned Above, the Specialties

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Professional Attire,” Tive Attributes Mentioned Above, the Specialties COMMENTARY On the Value of an Old Dress Code in the New Millennium S I WAS preparing to vertisements in medical journals as patients respond to them and los- deliver my annual well as from syndicated comic ing sight of the importance of self- lecture to the second- strips.2 Why do physicians and other reflection. year medical stu- health professionals choose to wear Are white coats then only a dents, I looked out white coats? The reason, in large cloak preventing the “real” us from Aover the audience and realized that measure, is tradition, but also being seen, or are they allowing us the attendees looked different from economy and convenience. Anthro- to be seen in a certain light, or do they those in years past: there were a sub- pologists and sociologists tell us that have any practical function, other stantial number of women (com- symbol and ritual are important to than perhaps to protect our under- pared with 5% in my class); some stu- all cultures; medicine as a societal lying clothes at the risk of cross- dents were unkempt and slouched, subculture is no different. Origi- contamination? White coats do al- reading nonmedical material (as op- nally beige, the white laboratory coat low the health care worker wearing posed to the bolt-upright, fearful, and has been in use since the late 19th them to bring assorted needed ma- attentive position in my day); and century, ostensibly to give physi- terials and tools to the patient’s side. none of the men was wearing a tie or cians a cloak of scientific validity for In a study out of London,6 the most white shirt (an integral part of the their treatments and to represent pu- common reasons cited for wearing uniform of the serious student up to rity and cleanliness: praiseworthy the white coat were (1) to be easily the 1970s). Obviously, these men and qualities in a healer. In 1993, to re- recognized by colleagues and pa- women were not aware of or chose mind physicians of their Hippo- tients (25%),(2) to carry needed to ignore Hippocrates’ advice that the cratic responsibilities, the Arnold P. medical items (23%), and (3) to keep physician should “be clean in per- Gold Foundation of Columbia Uni- underlying clothes clean (15%). Of son, well-dressed, and anointed with versity College of Physicians and the 29% of physicians and medical sweet smelling unguents.”1 I looked Surgeons, New York, NY, initiated students who did not wear white again at these differences and won- the “white coat ceremony” that is coats, 82% were in psychiatry or pe- dered, “Does it matter?” To answer now a rite of passage in most medi- diatrics; about 50% of these were try- this question, I reviewed the avail- cal and osteopathic schools in the ing to avoid the perceived, but erro- able literature in several electronic da- United States.3,4 Wear5 points out, neous, negative effect of the coat on tabases using search words such as however, that in addition to the posi- rapport with their patients in these “dress code,” “professional attire,” tive attributes mentioned above, the specialties. A few consultants wore “physician attitudes,” “white coat,” white coat potentially lends itself to suits to distinguish themselves from and “clothing.” Thirty-one articles multiple, conflicting interpreta- more junior faculty. were chosen to explore whether, ref- tions and can symbolize caregiving In an interesting study per- erence to gender aside, the old ad- hierarchies, economic and social formed at the University of Penn- age “clothes make the man” still con- privilege, and cronyism. Thus, sylvania, Philadelphia, investiga- tains a measure of truth, and whether whereas the white coat symbolizes tors convinced medical students, our patients actually feel comforted humanistic values in a formal cur- house staff, and faculty to empty the when they are approached by a medi- riculum, it also can symbolize more pockets of their white coats and then cal person in formal rather than ca- nefarious values, such as power and proceeded to evaluate the contents sual attire. authority, in a hidden curriculum. therein.7 Almost all persons carried Moreover, patients and nonphysi- medical equipment (eg, stetho- THE WHITE cian caregivers may interpret the scope, reflex hammer, penlight, and LABORATORY COAT white coat differently from the phy- calipers), and 90% of their coats con- sician, based on complex and highly tained pocket manuals such as the The white laboratory coat (fol- individual value systems. Physi- Sanford Guide to Antimicrobial lowed closely by the stethoscope) is cians need to be cautioned against Therapy. Students and residents were the universal symbol of the medi- becoming the coat, and thus failing much more likely than fellows or cal profession, as judged from ad- to be sensitive to the ways that their faculty to carry “to do” lists, phone (REPRINTED) ARCH INTERN MED/ VOL 163, JUNE 9, 2003 WWW.ARCHINTERNMED.COM 1277 Downloaded from www.archinternmed.com at University of Florida, on August 15, 2005 ©2003 American Medical Association. All rights reserved. numbers, and journal articles, while prudent, in view of the increasing ings, and dress shoes. Negative re- personal digital assistants were in- documentation of localized out- sponses were associated with ca- creasingly found in the pockets of breaks of Clostridium difficile and sual items such as sandals, clogs, those persons with advanced train- other pathogens in hospitals, to ex- athletic shoes, and scrub suits, with ing and higher salaries. The au- clude garments worn during the ex- blue jeans being the least accept- thors predicted that, in the future, amination of patients from nonclini- able form of attire. Not surpris- such electronic devices might well cal areas such as the cafeteria and ingly, older physicians favored a become as ubiquitous as today’s library. Who has not observed a house more traditional appearance than did pager. Of note was the observation staff officer or attending physician younger physicians. In another that pockets of medical students and scurrying from the parking lot to his study, by Gjerdingen et al,21 it was first-year residents were more or her place of work to see patients surprising that patients seemed to crowded than those of faculty; in- before returning again to the car, all have a more relaxed attitude to- deed, the white coat pocket of the the while wearing a set of hospital ward the appearance of their physi- chair of general internal medicine greens under a long white coat? An- cians than did the physicians them- carried only a pen. A confirmatory other example of a possibly negative selves. Three items, however, were study8 from Edinburgh, Scotland, effect of this symbol of the physician rated more positively by patients providing the comforting quantifi- is so-called white coat hyperten- than by physicians: name tags, vis- cation that physicians so like to see, sion, a popular term used by health ible stethoscopes, and groomed showed an inverse correlation be- care workers and lay people to refer moustaches. tween the mean weights of white to the phenomenon whereby blood coats and seniority, ranging from 1.7 pressure levels become transiently el- PATIENTS’ ATTITUDES kg for the coat of the junior house evated when measured by a physi- ON PROFESSIONAL ATTIRE: staff officer to approximately 1.0 kg cian. In one study, however, this phe- IT MATTERS for that of the senior attending/ nomenon occurred in 20% of patients consultant. with borderline hypertension when Is the medical profession’s tradi- The starched-white, clean ap- their blood pressure levels were mea- tional concern for professional at- pearance of a physician, however, sured by a physician rather than by a tire shared by our patients? Does it may not have totally salutary effects technician, regardless of profes- matter to our patients what we wear? on patients’ comfort levels or their sional attire.10 Therefore, in actual- These questions have been asked health parameters, and there may be ity, this phenomenon may not be as many times and have been an- caveats to consider when one is about much a consequence of attire as it may swered by the use of questionnaires to don this symbolic attire. Such coats be an anxiety reaction to the pres- and photographs of male and fe- are often worn while examining pa- ence of the physician or a condi- male physicians in various styles of tients with varied disorders in di- tioned response associated with sym- dress: the answer is a resounding, verse areas of the hospital, office, or pathetic arousal. The appearance and and almost universal, “Yes, it does outpatient setting, potentially allow- attire of the physician are by no means matter!” ing cross-contamination. In a study defined solely by the white coat, al- A multiple-choice question- of the microbiologic flora on physi- though, as we will see, it is the most naire was used to interview 200 pa- cians’ white coats, cultures were taken favored part of professional at- tients on the general medical ser- from the cuffs, front pockets, and tire11-16 or is second to the name tag vices of teaching hospitals in Boston, backs of 100 coats on physicians in as the most favored part,17-19 pre- Mass, and San Francisco, Calif.11 various specialties in a general hos- ferred by patients and physicians Specific questions concerned the pital.9 Staphylococcus aureus was iden- alike. wearing of a white coat, a necktie for tified in approximately 30% of male physicians, and a skirt for fe- samples. Interestingly, a “plateau PHYSICIANS’ ATTITUDES male physicians and whether ten- effect” was seen such that a steady ON PROFESSIONAL ATTIRE nis shoes and blue jeans were ac- state of maximal microbiologic con- ceptable for the physician to wear tamination was reached within the In a study specifically designed to in- during the patient visit.
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