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 overA 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. Slacks were first week of use and did not change vestigate physicians’ attitudes about not worn by female physicians as of- significantly thereafter. Moreover, their professional appearance, Gjerd- ten in the 1980s as they were in the dirty-appearing white coats did not ingen and Simpson20 distributed 1990s or today. Approximately one differ from clean coats in their level questionnaires to 35 residents and third of respondents had no prefer- or type of microbial contamination. 77 staff physicians in 2 Midwest resi- ences on most issues, but those with Also, almost 50% of the physicians dency programs. Questionnaires preferences expressed a clear mes- from whose coats S aureus was iso- asked for demographic and profes- sage: 65% believed that white coats lated carried the organism in their sional data, as well as about atti- should be worn, with only 7% feel- nose, suggesting an important role for tudes toward various items of ap- ing that they should not. The issue personal carriage in garment con- parel for male and female physicians. of a tie was more controversial, with tamination. Although the epidemio- Most participants showed positive re- 37% favoring and 33% not favoring logic evidence supporting the possi- sponses to traditional attire such as its use. Thirty-four percent of pa- bility of cross-contamination from the white coat, name tag, shirt and tients preferred that female physi- white coats is not strong, it still seems tie, dress pants, skirt or dress, stock- cians wear a skirt or dress during the

(REPRINTED) ARCH INTERN MED/ VOL 163, JUNE 9, 2003 WWW.ARCHINTERNMED.COM 1278 Downloaded from www.archinternmed.com at University of Florida, on August 15, 2005 ©2003 American Medical Association. All rights reserved. encounter, especially if the respon- 16% who felt the same way if the medicine clinics who perferred a dent was older than 55 years; there white coat was not worn. The mode white coat for the physician or nurse was no difference in response be- of dress for female physicians that preferred it to be closed, while only tween male and female patients; 27% would accomplish the same level of 6% preferred it to be open. did not prefer that mode of attire. trust and confidence was less well A questionnaire also was used Less acceptable were blue jeans and defined, with formal dress and white by Barrett and Booth24 to evaluate the tennis shoes, disapproved of by 53% coat and green scrubs and white coat positive and negative attributes as- and 27%, respectively; 43% and 48% being equally inspiring. A large num- signed to photographs of male and fe- of patients, respectively, preferred ber of patients in this study felt that male physicians in various manners their use. In general, house staff green scrubs were most defining for of attire in the outpatient depart- tended to be conservative in attire; a female physician and best in- ment of Children’s Hospital in Bir- however, house staff were found to spired their trust and confidence by mingham, Ala. Seventy percent of 203 have less formal dress habits than a avoiding the potential confusion of consecutive child-parent pairs rated substantial portion of their pa- a female physician in a dress with a physicians’ dress as important, with tients preferred. Of 74 physician re- secretary or one in a white coat with more children rating it “very impor- spondents, 67 (91%) never wore a dietician, nurse, or social worker. tant.” Men and women in white coats blue jeans and 42 (57%) never wore The issue of appropriateness of were regarded by 44% of the chil- sneakers when seeing patients. professional attire also has been ad- dren as most competent among phy- Forty-four (85%) always wore a tie, dressed frequently in the pediatric sicians in various dress styles, but of and 57 (77%) sometimes (36 [49%]) and emergency medicine litera- lesser friendliness. In casual dress, or always (21 [28%]) wore a white ture. In one study performed in a male and female physicians were coat. There was but minor variance general teaching hospital affiliated rated most friendly and gentle, but of in attire that was geographic spe- with the University of Alberta, Ed- lesser competence. Parents pre- cific: ties were more commonly worn monton, it was clearly shown that ferred more casual dress but ex- in Boston (33 [97%] of 34 male phy- a relationship exists between house pressed preferences less strongly than sicians vs 11 [61%] of 18 male phy- staff physician attire and parents’ ini- their children, and they predicted sicians), whereas blue jeans were tial perceptions of competence.13 A poorly which attire their children more often worn in San Francisco (6 series of study photographs were cre- would prefer. The issue of friendli- [20%] of 30 physicians vs 1 [2%] of ated using 3 dress variables for male ness and gentleness, or perhaps fa- 44 physicians). Nineteen (86%) of and female physicians (formal street miliarity, may in part help to ex- 22 female physicians always (2 clothes and a long white coat; an in- plain the findings of a study from [18%]) or sometimes (15 [68%]) tern’s uniform of a short white jacket, Groningen, the Netherlands, in wore a skirt or dress. Regardless of casual shirt, casual shoes, and white which preference of children for a geographic location, older patients pants or casual slacks; and operat- physician in a white coat or infor- tend to be more conservative in their ing room “greens” with a short white mal dress was shown to depend on expectations of what constitutes intern’s jacket and casual shoes). the child’s medical history.25 The proper professional attire. In an- Photographs of the 15 possible more extensive the medical history, other study performed in northern paired-gender combinations were the more the preference shifted to the Norway, there was a clear trend for shown to visiting parents of chil- informally dressed physician. patients, especially female patients, dren on pediatric inpatient units who Another study used photo- to want their physicians to wear were asked to choose the more com- graphs of male and female physi- white coats during office consulta- petent of each pair. Formal dress was cians dressed in 5 styles of attire tion, a trend that increased with ad- preferred at a highly significant level, ranging from formal (short white vancing age of the patient.12 with no gender preference. Of note coat and tie [male] or skirt [fe- In many studies, including one was that attire preference and per- male] to informal (open shirt or conducted in 2 family practice set- ception of competence were less blouse and slacks without a white tings (one site located in an urban common in parents with a univer- coat).26 In an outpatient facility, chil- hospital-based unit and another site sity education and those who had dren older than 5 years and their par- in an outpatient clinic in a north- not previously had a hospitalized ents were asked to match a list of ern pulp and paper mill town in On- child than in parents with less positive and negative attributes (eg, tario, Canada), most patients felt that schooling or those who had had a most or least competent, friendly, physician dress influenced their trust hospitalized child. The article con- concerned, and gentle) to the pho- and satisfaction and believed that a cluded, “at the very least it would tographs and to choose the one pre- physician should dress “profession- seem desirable to consider the in- ferred most or least. Both parents and ally.”22 Of note, 36% of the 80 pa- advertent reduction in parents’ per- children gave positive attributes to tients in the latter study and 47% of ceptions of competence associated men and women dressed formally those older than 70 years said that with the intern uniform. . . . The and viewed the informally attired they dressed specifically to see their simple white lab coat may still be the physicians negatively. Children’s physician. Sixty percent felt that a appropriate order of the day.” More- preferences were neither as strong male physician in a tie, dress suit, over, in a study from Ben Gurion nor as clear as those of their par- and white coat most inspired trust University in Beer-Sheva, Israel,23 ents and, while they had no strong and confidence, followed by only 50% of 130 patients in 3 family positive preferences, children

(REPRINTED) ARCH INTERN MED/ VOL 163, JUNE 9, 2003 WWW.ARCHINTERNMED.COM 1279 Downloaded from www.archinternmed.com at University of Florida, on August 15, 2005 ©2003 American Medical Association. All rights reserved. seemed to feel negatively about in- gency physicians in a community physician’s appearance. However, formal attire, especially the lack of hospital in Pennsylvania. Seventy- nearly 46 (30%) of 161 patients in- a tie or white coat in a male physi- three percent of physicians and 43% correctly identified their physician cian and the use of slacks without a of patients thought that physical ap- as wearing a tie when no tie was white coat in a female physician. pearance influenced patients’ opin- worn, and of 96 patients who Children also had somewhat stron- ions of medical care. Again, pa- thought they recalled their physi- ger responses to male attire than to tients were more tolerant of casual cian wearing a tie on the day when female attire, suggesting greater lati- dress than were physicians, but both he was in fact not wearing one, 46 tude in dress codes for women. groups disliked excessive jewelry, (48%) perceived it incorrectly. Pa- In yet another study in the out- prominent ruffles or ribbons, long tients were much more accurate patient setting using photographs, fingernails, blue jeans, and sandals. when their physician was truly wear- this one from Western Ontario, 101 The most liked dress item for both ing a tie, with only 4 (4%) of 104 err- children ranging in age from 4 to 8 patients and physicians again was the ing in their perception; the percep- years and their parents were shown name tag, followed by the white coat, tion of the wearing of the tie was 2 pairs of photographs: the same but both were of lesser importance correlated with a positive impres- man and woman each with and with- than either personality or a neat, sion of the physician’s appearance. out a white coat.17 Both child and clean appearance. Short hair and a Wearing or not wearing a tie did not parents were asked which physi- shirt and tie edged out the visible affect the patients’ impression of cian they would prefer to have as stethoscope as desired elements of their physician or the care they re- their own or as their child’s physi- appearance. Neatness also was cited ceived, but patients did seem to pre- cian, respectively. Both selected the as of most concern in 2 other stud- fer the appearance of physicians person wearing the white coat two ies.14,28 In a study by Blondell et al,14 whom they perceived to wear ties. thirds of the time! On a question- all patients commented on the phy- In the pediatric emergency de- naire rating the appropriateness of sician’s demeanor, and facial expres- partment, Gonzalez del Rey and various aspects of the physicians’ at- sion overrode concern about attire. Paul15 showed that emergency phy- tire and appearance, parents iden- The authors concluded with an ad- sicians’ attire did not matter to most tified the name tag as the most ap- visement that while traditional con- parents/guardians. However, when propriate item of dress, followed by servative dress might not be neces- the parents or guardians were asked the white coat. A groomed mous- sary, it was important to wear a white to choose among photographs of phy- tache and groomed beard also were coat, have an overall clean, neat ap- sician pairs in dress ranging from for- rated favorably. The most negative pearance, and have a pleasant ex- mal (white laboratory coat, tie, and ratings were given to clogs, open- pression, thereby displaying confi- dress shoes) to surgical scrubs with toed sandals, shorts, and blue jeans, dence and concern. In a study by tennis shoes, clear preferences were while long hair and earrings for male Friis and Tillis,28 while most pa- evident: 75% preferred the formal at- physicians and dangling earrings for tients in 4 clinical settings main- tire and 84% chose the photographs female physicians were perceived tained by the University of Califor- of physicians who wore tennis shoes somewhat negatively. Parents were nia, Irvine, Medical Center had no as the least preferred physician. How- neutral about the shirt-and-tie look, preference regarding attire, the ma- ever, the formal attire was preferred hospital scrubs, blouse and skirt, or jority did feel that neatness was mod- more by subjects visiting the emer- dress. In other studies,18-21,23 the erately to very important. gency department between 7 AM and name tag also was selected as the A controversial piece of profes- 11 PM than it was by those visiting be- single most suitable dress item for sional formal attire is the tie. Should tween 11 PM and 7 AM. A majority a male or a female physician. it be worn as part of an attempt to (72%) of parents/guardians did feel In one study devoted to the feel- make our patients predict our com- that the physician they preferred most ings of adolescents, there was no ex- petence? In the above-mentioned in the photograph might not be nec- pressed association between the studies, there was evidence to sug- essarily more capable than the other comfort level of the adolescents and gest an overall positivity for this ac- choices. Parents of children with sur- their physicians’ dress style, al- cessory when it was part of a rela- gical emergencies, however, were though 85% of the adolescents sur- tively formal look. In an interesting more likely to prefer physicians in veyed did prefer that their physi- study designed to determine the surgical scrubs. Explanations of re- cians not “dress like them,” and 78% effect of wearing a tie by physicians spondents who chose the picture of felt that their physicians “dressed as as the only variable of attire, 316 a physician in formal dress were a doctor should dress.”27 emergency department patients dis- “looks professional,” “serious and ex- Studies also have been per- charged from a community teach- perienced doctors,” or “clean”; dis- formed in emergency departments, ing hospital in Pennsylvania were likes for the informally clad in- where patients have little choice in prospectively followed up.29 Physi- cluded “sloppy,” “coming off the their physicians and severity of ill- cians were randomly assigned by street,” and “doesn’t look like doc- ness is of preeminent concern. Colt dates to wear a tie or not, their at- tors.” The most popular single items and Solot18 did a cross-sectional sur- tire being similar in all other re- of formal attire were the laboratory vey of 190 emergency department gards. No significant differences coat (65%) and tie (54%), while ten- patients and various specialists, fam- were recorded between groups, in- nis shoes were the least favored item ily practitioners, surgeons, and emer- cluding patients’ perception of their (84%).

(REPRINTED) ARCH INTERN MED/ VOL 163, JUNE 9, 2003 WWW.ARCHINTERNMED.COM 1280 Downloaded from www.archinternmed.com at University of Florida, on August 15, 2005 ©2003 American Medical Association. All rights reserved. PATIENTS’ ATTITUDES ponent of the patient-physician 5. Wear D. On white coats and professional devel- 16 opment: the formal and hidden curricula. Ann In- ON PROFESSIONAL ATTIRE: relationship. In this questionnaire- tern Med. 1998;129:734-777. IT DOES NOT MATTER driven study, which was the first in 6. Farraj R, Baron JH. Why do hospital doctors wear the Japanese-language literature to white coats? J R Soc Med. 1991;84:43. 7. Lynn LA, Bellini LM. Portable knowledge: a look A recent study in the dermatology lit- evaluate the effect of physician at- inside white coat pockets. Ann Intern Med. 1999; erature reaffirmed patients’ prefer- tire on the patient, patient satisfac- 130:247-250. ences for their physicians to be for- tion with the consultation was not in- 8. Gordon PM, Keohane SG, Herd RM. White coat effects. BMJ. 1995;311:1704. mally attired, just as in the many fluenced by whether the consultant 9. Wong D, Nye K, Hollis P. Microbial flora on doc- studies published decades ago,30 but wore a white coat or “private clothes.” tors’ white coats. BMJ. 1991;303:1602-1604. 10. Pickering TG, James GD, Boddie C, Harshfield GA, in 3 of the 31 studies that I reviewed, However, elderly patients and those Blanks, Laragh JH. How common is white coat hy- physician attire was shown not to seen by physicians who were wear- pertension? JAMA. 1988;259:225-228. affect overall patient satisfaction with ing a white coat preferred the white 11. Dunn JJ, Lee TH, Perceley JM, Fitz JG, Goldman 16,19,31 L. Patient and houseofficer attitudes on physi- care. In the first, out of Notting- coat to private clothes because of cian attire and etiquette. JAMA. 1987;257:65-68. ham, England, a male anesthetist cleanliness, image of the physician, 12. Anvik T. Doctors in a white coat—what do pa- made a preoperative visit to each of trust, and professionalism; reasons tients think and what do doctors do? Scand J Prim Health Care. 1990;8:91-94. 2 groups of patients and alternately not to prefer the white coat in- 13. Taylor PG. Does dress influence how parents first dressed for the visit either in a suit cluded a relaxed relationship, friend- perceive staff competence? AJDC. 1987;141:426- 428. and tie or in an open-necked shirt, liness, and equality. 14. Blondell RD, Humble RS, Roberts DM. Patients 19 jeans, and training shoes. While pa- and the habits of house officers [letter]. JAMA. tient satisfaction was not influenced CONCLUSIONS 1987;257:2031. 15. Gonzalez del Rey JA, Paul RI. Preferences of par- by the physician’s attire, and words ents for pediatric emergency physicians’ attire. Pe- descriptive of professionalism and ad- It appears that the attire of the health diatr Emerg Care. 1995;11:361-364. jectives suggesting approachability care provider is important to pa- 16. Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude toward consultations by a physician with- were used equally by similar num- tients across all lines of population out a white coat in Japan. Intern Med. 1999;38: bers of patients in each group, spe- and geography studied to date: 533-536. 17. Matsui D, Cho M, Rieder M. Physicians’ attire as cific items of dress were “firmly” se- young or old, child or parent, east- perceived by young children and their parents: the lected or rejected by the patients who ern or western, northern or south- myth of the white coat syndrome. Pediatr Emerg were interviewed. Most desirable ern. A neat, clean appearance, how- Care. 1998;14:198-201. 18. Colt H, Solot JA. Attitudes of patients and physi- (90%) was a name tag, followed by a ever, is more important than attire. cians regarding physician dress and demeanor in white coat (65%), polished shoes Among professional apparel, the the emergency department. Ann Emerg Med. 1989; (62%), and short hair (57%). Largely name tag and the white coat are most 18:145-151. 19. Hennessy N, Harrison DA, Aitkenhead AR. The disapproved were clogs (84%), ear- preferred by patients. In general, effect of the anaesthetist’s attire on patient atti- rings (64%), long hair (62%), jeans physicians are more conservative in tudes. Anaesthesia. 1993;48:219-222. 20. Gjerdingen DK, Simpson DE. Physician’s atti- (70%), and training shoes (67%). their opinions about their attire than tudes about their professional appearance. Fam Once again, older patients were more are their patients. Older patients es- Pract Res J. 1989;9:57-64. conservative in their choice of attire pecially, but individuals in all age 21. Gjerdingen DK, Simpson DE, Titus SL. Patients’ and physicians’ attitudes regarding the physi- for their physicians. ranges, tend to favor more formal cians’ professional appearance. Arch Intern Med. The second study involved phy- dress; formal need not mean stiff and 1987;147:1209-1212. sicians and physician assistants in an uncaring. There is no substitute for 22. McNaughton-Filion L, Chen JSC, Norton PG. The physician’s appearance. Fam Med. 1991;23:208- emergency clinic setting in Spring- a gentle, concerned physician with 211. field, Mass.31 In that study, health an engaging, friendly, empathic de- 23. Menachem S, Shvartzman P. Is our appearance important to our patients? Fam Pract. 1998;15: care providers wore a white coat with meanor. Is attire important? Yes! Is 391-397. surgical scrubs on even days and a personality important? Yes. Every- 24. Barrett TG, Booth IW. Sartorial eloquence: does white lab coat with formal attire thing is important! it exist in the paediatrician-patient relationship? BMJ. 1994;309:1710-1712. (shirt, tie, and slacks for men and a 25. Zwart DLM, Kimpen JLL. The white coat in pedi- dress or blouse and slacks for wom- Lawrence J. Brandt, MD, MACG atrics: link between medical history and prefer- en) on odd days. A questionnaire did Albert Einstein College of Medicine ence for informally dressed physicians [in Dutch]. Ned Tijdschr Geneeskd. 1997;141:2020-2024. not reveal any difference that was at- Montefiore Medical Center 26. Marino RV, Rosenfeld W, Narula P, Karakurum M. tire related for the providers’ cour- 111 E 210 St Impact of pediatricians’ attire on children and par- ents. J Dev Behav Pediatr. 1991;12:98-101. teousness, concern for the patient’s Bronx, NY 10467 27. Neinstein LS, Stewart D, Gordon N. Effect of phy- problem and comfort, or the medi- (e-mail: [email protected]) sician dress style on patient-physician relation- cal skill and knowledge of the pro- ship. J Adolesc Health Care. 1985;6:456-459. 28. Friis R, Tillis J. Patients’ preferences for resident vider. The authors expressed the be- REFERENCES physician dress style. Fam Pract Res J. 1988;8: lief that attitude, mannerism, and 24-31. professionalism of the treating phy- 29. Pronchik DJ, Sexton JD, Melanson SW, Patter- 1. Jones WHS, trans. Hippocrates. Vol 2. Cam- son JW, Heller MB. Does wearing a necktie influ- sician have more of an influence on bridge, Mass: Harvard University Press; 1923: ence patient perceptions of emergency depart- patient satisfaction than does phy- 311-312. ment care? J Emerg Med. 1998;16:541-543. 2. Blumhagen DW. The doctor’s white coat: the im- 30. Kanzler MH, Gosulowsky DC. Patients’ attitudes sician attire. age of the physician in modern America. Ann In- regarding physical characteristics of medical care The third study was performed tern Med. 1979;91:111-116. providers in dermatologic practices. Arch Der- in a university clinic in Japan, a coun- 3. Enoch BE. The gold standard. J Coll Phys Surg matol. 2002;138:463-466. Columbia Univ. 1998;18:11-13. 31. Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. try where communication only re- 4. Branch WT Jr. Deconstructing the white coat. Ann The influence of physician attire on patient satis- cently was recognized as a vital com- Intern Med. 1998;129:740-742. faction. Acad Emerg Med. 1998;5:82-84.

(REPRINTED) ARCH INTERN MED/ VOL 163, JUNE 9, 2003 WWW.ARCHINTERNMED.COM 1281 Downloaded from www.archinternmed.com at University of Florida, on August 15, 2005 ©2003 American Medical Association. All rights reserved.