= 0.252). s most likely P ’ = 0.001). P sport medicine or foot and ankle 0.05) for all attire except a business ’ , P 0.005). Patients found women in feminine , P s Attire on Patient ’ In orthopaedic surgery, limited research is available Women surgeons who wear feminine business attire An image-based survey was offered to all adult patients Two hundred thirty-eight patients participated in the survey. addressing how attire, including white coatsattire (WC) such as and skirts, feminine affects patient perceptions. It issurgeon unknown appearance how is associated with identification as aand surgeon perception of clinical skills, normale whether and this female differs surgeons. between in four orthopaedic surgeons clinics. Respondents viewed 10 photosmodels in of varying male attire and and identified female that individual role on the healthcare team.respondents selected Then, which in surgeon showed 10 more photos competence, ability to pairs, excel in performing the physicallikelihood components to of surgery, provide a goodtrustworthiness. surgical outcome, and instead of scrubs may be perceived lessphysical able work to of perform operating, the but are otherwisewith rated their comparably peers, both male and female.generally Surgeons perceived wearing more WC favorably are than those without WC,effect an that is magnified for perceptions ofsurgeons. competence Men for are more female readily identified as surgeons than women when wearing a similar attire, except forWC. a There are business continuing attire differences in without how patients perceive male and female orthopaedic surgeons based on their attire. Discussion: Results: Methods: Abstract Introduction: Men were identified as surgeons significantlywomen more in frequently similar than clothing ( attire without a WC (men: 18.2% vs women: 11.2%; Patients ranked physicians wearing acompetent WC and with more any likely attire tothose as give without more a (all good surgicalattire significantly outcome less than likely to excelof in performing surgery the than physical women parts in scrubs ( Research Article The Effect of an Orthopaedic Surgeon Perceptions of Surgeon TraitsIdentity: and A Cross-Sectional Survey 2020;4: e20.00097 DOI: 10.5435/ JAAOSGlobal-D-20-00097 Copyright © 2020 ThePublished Authors. by Wolters KluwerInc. Health, on behalf ofAcademy the of American Orthopaedic Surgeons. This is an opendistributed access under article the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproductionany in medium, provided thework original is properly cited. From the Department ofand Orthopedics Rehabilitation (Dr. Goldstein, Dr. Klosterman, Dr. Grogan, Dr. Williams, Dr. Guiao,University Dr. of Spiker), Wisconsin-Madison, Madison, WI, and theBiostatistics Department and of Medical Informatics (Mr. Hetzel), University ofMadison, Wisconsin- Madison, WI. Correspondence to Dr. Spiker: [email protected] JAAOS Glob Res Rev Kathryn L. Williams, MD Ronald Guiao, MD Andrea M. Spiker, MD Stephanie D. Goldstein, MD Emma L. Klosterman, MD Scott J. Hetzel, MS Brian F. Grogan, MD

Downloaded from https://journals.lww.com/jaaosglobal by k38zdtHxkv4GqUtrpBilxtXPiQltBCEnd56BCsLF3VGyxLAw00j7jhX/1xcfEAWat8CjlzWAuLw2aZ43C41u30NndeE1Virrudr0rlEnPOtjlMB6C7PSNGPF/Gk12Gc9IwzU9H/2qSy9AdDpeYfk9Q== on 08/11/2020 Downloaded from https://journals.lww.com/jaaosglobal by k38zdtHxkv4GqUtrpBilxtXPiQltBCEnd56BCsLF3VGyxLAw00j7jhX/1xcfEAWat8CjlzWAuLw2aZ43C41u30NndeE1Virrudr0rlEnPOtjlMB6C7PSNGPF/Gk12Gc9IwzU9H/2qSy9AdDpeYfk9Q== on 08/11/2020 Effect of Orthopaedic Surgeon Attire

hysician appearance and attire forming the physical components Based on existing literature of bias has been the subject of numerous 9,10 P of surgery. in the medical profession, we publications over the past three dec- The WC, historically worn pri- hypothesized that female models ades. As an easily modifiable factor marily by physicians, has since wearing feminine attire would be that may influence patient percep- become a marker of the healthcare rated less favorably than men for tions, satisfaction, and even out- profession more broadly. Orthopae- traits referencing surgical skill and comes, there has been understandable dic surgeons rely heavily on physician strength, that patients would rate interest in defining the ideal attire that extenders, including physician assis- models wearing WCs as more correlates most closely with desirable tants (PAs) and nurse practitioners, favorable and more likely to be professional traits. A recent multicen- to improve many aspects of their surgeons, and that women will be ter study including over 4000 patients practices.7,8 Many nonphysicians identified as surgeons less frequently receiving nonsurgical inpatient or involved in orthopaedic care may than males. outpatient care found that formal don a WC during their clinical du- attire with a white coat (WC) was the ’ ties. In the authors experiences, Methods most highly rated attire and that one- youthful-appearing surgeons and third of patients agreed that their female surgeons have experienced This study was approved by our doctor’s appearance influenced their misidentification as a nonphysician institutional review board. Four satisfaction with care.1 However, the member of the healthcare team, such fellowship-trained orthopaedic sur- physician traits that are most desir- as a nurse or PA. The extent to geons in an academic practice re- able and salient for patients may vary which a WC helps distinguish the cruited patients from their outpatient among medical specialties. Ortho- surgeon from other members of the clinics. Two of these orthopaedic paedic surgery is unique in that it healthcare team and how this differs surgeons subspecialized in sport involves manual tasks in the oper- between male and female physicians medicine and two in foot and ankle, ating room that patients may remains unknown. with one male and female surgeon in associate with a need for physical We sought to answer the following each subspecialty. All patients older strength, which is more commonly questions: than the age of 18 presenting to an associated with men than women. (1) Does feminine business attire eligible outpatient orthopaedic clinic Although the number of women in affect patient perceptions of were invited to participate in the orthopaedic training and practice four realms of surgical and study before being seen by a physi- is slowly increasing, orthopaedic clinical skills (competence, cian extender or the attending sur- surgery remains a male-dominated ability to provide a good sur- geon. Patients were informed that specialty. As of 2016, only 4% of gical outcome, ability to excel their participation was voluntary and the members of the American in the physical parts of surgery, that their responses were anony- Academy of Orthopaedic Surgeons and trustworthiness) or iden- mous. They were given the option to (AAOS) and 13% of orthopaedic tification as a surgeon? take the survey in paper form, in surgery residents were women.2 A (2) Does wearing a WC affect electronic form on a provided tablet, number of published studies look patient perceptions of four or via a QR code on their smart- specifically at the role of surgeon realms of surgical and clinical phone. Questions could be skipped in appearance in orthopaedic surgery, skills or identification as a all versions. many of which feature male and surgeon? During the study period, partici- female surgeons in varying attire.3- (3) How readily do patients iden- pating surgeons wore consistent 6 No study to date has looked tify women as surgeons as attire to each clinic. The type of attire specifically at the impact of femi- compared to men when an was based on personal preference. nine attire, such as skirts or dres- identical attire is worn? Female surgeon XX wore feminine a ses, on patient perceptions of (4) Are female surgeons in any business attire (skirts or dresses) orthopaedic surgical skill, includ- attire perceived differently without a WC, female surgeon XX ing the ability to excel in per- than male surgeons? wore business clothing with a WC,

Dr. Williams or an immediate family member serves as a paid consultant to DePuy, Globus Medical, Medtronic, and Stryker; has stock or stock options held in Titan Spine; serves as a board member, owner, officer, or committee member of ISASS and the North American Spine Society. Dr. Spiker or an immediate family member serves as a paid consultant to Stryker. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Goldstein, Dr. Klosterman, Mr. Hetzel, Dr. Grogan, and Dr. Guiao.

2 Journal of the American Academy of Orthopaedic Surgeons Stephanie D. Goldstein, MD, et al

Figure 1

Photographs of male and female models used for identification portion of survey. male surgeon XX wore a business (Figure 1). The third “comparison” model images included a business attire with a WC, and male surgeon section presented one of 10 pairs of attire (blue blouse and dark pants), XX wore either a business attire photos and asked respondents to feminine business attire (same blue without a WC or scrubs with a WC. select which surgeon fit more closely blouse amd dark skirt), and scrubs, An image-based survey was created with one of four traits: competence, each with and without a WC. comprising three parts (see supple- ability to excel in performing the Statistical analyses were based on mental materials, http://links.lww. physical parts of surgery, likely to the following hypothesis questions: com/JG9/A81). The first collected provide a good surgical outcome, (1) What types of attire and model sex demographic information, including and trustworthiness. An option of combinations were most likely to be sex, age, race, education level, home “they seem the same” was also classified as a surgeon? (2) Which setting (urban, suburban, or rural), provided. The 10 photograph pair- picture in the direct comparisons did and type of visit (new, returning, ings were chosen to answer the patients say was most consistent with postoperative, or emergency depart- questions outlined in the introduc- the listed trait? (3) Did any patient ment follow-up). The second “iden- tion section (Figure 2). The order of characteristics influence the out- tification” section presented 10 pictures within a question and a comes of questions 1 and 2? photos of our male or female model given section were randomized. We calculated the percentage rate in varying attire and asked re- An internal medicine intern and an of surgeon classification for each of spondents to identify their most orthopaedic surgery intern who had the 10 identification photos. We likely role on the healthcare team not yet worked in the participating compared the percentages in all two- (surgeon, PA, nurse, medical assis- orthopaedic subspecialty clinics vol- way comparisons via Fisher exact test tant, hospital administrator, or oth- unteered as models and provided with Holm adjustment for 45 multi- er). Descriptions of each role were consent for his/her image to be used in ple comparisons. To determine which provided as needed. Photos used in publication. The male model images picture was selected most frequently this section were taken in a hallway included a business attire (blue shirt, in the comparison section, we to make them applicable to either tie, and dark pants) and scrubs, each removed “they seem the same” re- an inpatient or outpatient setting with and without a WC. The female sponses, calculated the percentage

August 2020, Vol 4, No 8 Effect of Orthopaedic Surgeon Attire

Figure 2

Photographs of male and female models used for comparison portion of survey. for one of the pictures in the dyad, graphics and clinic information are in the age of 50 were more likely to and tested the percentage by a two- Table 1. Nearly all (95.1%) of the identify a woman in a business attire sided test of a single proportion respondents reported that they did and WC as a surgeon than those older versus a null hypothesis of 50%, not recognize the models in the survey than 50 (70.4% vs 50.4%; P = 0.032), which is the expected rate because of photos. Most patients completed the who associated this attire with non- random chance. This was repeated surveys on a tablet, whereas 6.7% surgeons, primarily PAs. Respondents for each of the four subquestions. elected to complete the survey on younger than 50 years old identified P values from the 10 tests within paper. The most common reason for women in scrubs only as surgeons each subquestion were Holm adjusted the appointment was a postoperative more frequently than did their older to account for multiple testing. Com- visit (43.6%); male and female ortho- than 50 counterparts, but this did not parisons based on patient character- paedic surgeons were nearly equally reach statistical significance after istics were done via Fisher exact likely to have performed a surgery on multiple comparison adjustment tests and also used Holm adjust- theirpatients(48%versus52%of (28.7% vs 13.9%; P = 0.087). Those ments for multiple comparisons. An postoperative patients, respectively). who were college graduates identified adjusted 5% significance level was More than half (57.5%) of the re- women in a business attire without used for all tests. Analysis was spondents reported that their primary WC as surgeons more frequently than performed in R for statistical com- care physician was the same sex as noncollege graduates (18.7% vs 4.8%; puting version 3.5. themselves, whereas 47.5% of re- P = 0.016). For the remainder of the spondents were the same sex as their identification questions, no differences Results orthopaedic surgeon. between age groups were found for Respondent age, sex, education level, other types of attire, nor for the other From August to October 2019, 238 and the subspecialty and sex of the above-listed demographic criteria. patients participated in the survey, surgeon they saw in clinic did not Summative findings for the sur- representing 32% of the eligible influence responses to the comparison vey’s identification portion are in clinic population. Participant demo- questions. Respondents younger than Figure 3.

4 Journal of the American Academy of Orthopaedic Surgeons Stephanie D. Goldstein, MD, et al

Does Feminine Business Table 1 Attire Affect Patient Characteristics of Study Respondents and Clinic Attendings Perceptions of Four Realms Total Survey of Surgical and Clinical Skills Characteristics Responses = 238 or Identification as a Surgeon? Patient age n = 238 18-25 24 (10.1%) Aggregated responses for the com- 26-34 29 (12.2%) parison questions can be found in 35-49 59 (24.8%) Table 2. Patients found women in 50-65 88 (37.0%) feminine attire with WCs signifi- 66-80 36 (15.1%) cantly less likely to excel in per- 811 2 (0.8%) forming the physical parts of surgery Patient sex n = 217 than the women in scrubs with WCs Male 98 (45.4%) (8.4% to 24.3%, P = 0.001). Oth- Female 118 (54.4%) erwise, women in feminine attire were rated comparably with women Highest education achieved n = 235 in a business attire and scrubs, as Before high school 2 (0.9%) well as to men in a business attire for High school graduate 40 (17.4%) their competence, surgical outcomes, Some college 87 (37.8%) ’ physical ability and trustworthiness. Bachelor s degree 64 (27.8%) ’ No difference was observed in how Master s degree 28 (12.2%) frequently women in feminine attire Doctorate degree 9 (3.9%) a with a WC (61.4%) were identified as Race n = 242 surgeons compared with women in Caucasian 223 (92.2%) other attire with WCs (scrubs: 57.3% Black or African American 4 (1.7%) and business attire: 59.7%; P . Hispanic 6 (2.5%) 0.999). For an attire without WCs, American Indian or Alaska Native 4 (1.7%) women in scrubs (20.9%) were Asian 2 (0.8%) identified as surgeons more fre- Native Hawaiian or Pacific 1 (0.4%) quently than women in both busi- Islander ness (11.2%; P = 0.046) and Other 1 (0.4%) feminine attire (8.3%; P = 0.003). Living area n = 234 Rural 76 (32.5%) Suburban 91 (38.9%) Does Wearing a White Coat Urban 67 (28.6%) Affect Patient Perceptions of Appointment type n = 234 Four Realms of Surgical and New patient 58 (24.8%) Clinical Skills or Postoperative visit 102 (43.6%) Identification as a Surgeon? Returning patient 68 (29.1%) Respondents uniformly ranked male Emergency department follow-up 0 (0%) and female orthopaedic surgeons Other 6 (2.6%) wearing WCs on top of any attire as Attending specialty n = 229 more competent and more likely to Sport medicine 168 (73.4%) give a good surgical outcome than Foot & ankle 61 (27.6%) those without a WC (P , 0.005), Attending sex n = 229 although a large proportion of par- Male 110 (48.0%) ticipants indicated that the presented Female 119 (52.0%) models “seem the same” for each (continued) question (Table 2). Adding a WC PCP = primary care physician over a business attire for both sexes aEach respondent was allowed to select more than one response. bIndicates patients whose sex matches that of their reported PCP. increased perceived superiority in

August 2020, Vol 4, No 8 Effect of Orthopaedic Surgeon Attire

Table 1 (continued) chosen most frequently. Women in scrubs with a WC were judged more Characteristics of Study Respondents and Clinic Attendings likely to give a good surgical out- Total Survey come and more trustworthy than Characteristics Responses = 238 men in the same attire (12.8% versus 3.9%, P = 0.018; 14.4% versus Patient PCP sex n = 206 3.1%, P = 0.002, respectively). Male 86 (41.8%) Female 104 (50.5%) Do not have/prefer not to say 16 (7.7%) Discussion Sex-matched PCPb 119 (57.5%) This study of 238 patients from PCP = primary care physician a Each respondent was allowed to select more than one response. sport medicine and foot and ankle b Indicates patients whose sex matches that of their reported PCP. orthopaedic subspecialty clinics demonstrated that surgeon attire affects patient perceptions of sur- physical ability (male: 6.9% to comparably dressed. Notably, a man geon skill and that attire influences 36.6%, P , 0.001; female business: wearing a business attire with a WC whether a provider is identified as a 3.4% to 43.8%, P , 0.001; female was identified as a surgeon 79.4% surgeon. skirt: 4.1% to 43%, P , 0.001), of the time, whereas a woman In this study, respondents uni- whereas adding a WC over scrubs wearing a WC with business pants or formly ranked physicians wearing did not change the perception of skirt was identified as a surgeon WCs over any attire as more compe- physical ability for either sex (male: 59.7% or 61.4% of the time, tent and more likely to give a good 20.2% to 20.2%, P = 1; female: 17.1% respectively (both P , 0.001). A surgical outcome than those without. to 26.4%, P =0.318).Surgeonswere woman in scrubs without a WC was Surgeons wearing a WC over any perceived as more trustworthy when identified as a nurse by 50.4% of type of business attire, including wearing a WC with male business attire respondents and as a surgeon by skirts, were deemed more likely to (9.4% to 26%, P = 0.001), female only 20.9%. In comparison, a man excel in the physical parts of sur- scrubs (11.1% to 22.6%, P =0.043), in scrubs without a WC identified gery; for surgeons in scrubs, no female business attire (5.1% to 30.6%, as a nurse 39.8% and surgeon statistical difference was observed P , 0.001), and female skirt attire (3% 33.8% of the time (P = 0.031). between those with or without a to 32%, P , 0.001). Male orthopaedic Wearing a WC with scrubs increased WC. In many recent studies, pa- surgeons in scrubs with and without the rate of identification as a surgeon tients have indicated a general WCs had similar trustworthiness rat- for women to 57.3% and for men to preference for doctors to wear WCs. ings (14.2% to 20.3%, P =0.55). 73.8%. Both men and women in a In a multicenter study by Petrilli In the identification section, male business attire (including skirts) et al1 of nonsurgical patients, over and female models wearing a WC without WCs were most frequently half of the patients agreed or were unanimously identified as a identified as hospital administrators. strongly agreed that doctors should surgeon more often than those in the wearaWCwhenseeingpatientsin same attire without a WC (all P , the hospital or in their office. Lands Are Female Surgeons in Any 0.001) (Table 3). found that patients in an ortho- Attire Perceived Differently paedic hand clinic consistently gave than Male Surgeons? How Readily Do Patients the highest ranking to male and In the comparison section, re- female surgeons wearing a WC in Identify Women as Surgeons spondents frequently indicated no seven patient-perceived qualities.5 as Compared to Men When preference between the presented In our study, no comparisons ex- an Identical Attire is Worn? pairs of photos. The option of “they isted where a greater number of Significant differences were found in seem the same” was chosen most respondents preferred the model how respondents identified male and frequently for all comparisons except without a WC to one with a WC. female surgeons wearing a compara- for the three questions assessing Therefore, for most patients who ble attire (Table 4). A man in any competence for female attire with indicated a preference, a WC seems to attire was identified as a surgeon and without a WC. There, the image increase association with positive more frequently than a woman of the model wearing a WC was traits.

6 Journal of the American Academy of Orthopaedic Surgeons Stephanie D. Goldstein, MD, et al

Although the WC may be viewed Figure 3 favorably by patients, there has been concern about WCs as potential fo- mites that contribute to the spread of bacteria among hospitalized patients. In 2007, hospitals in the United Kingdom began a “bare below the elbows” policy to address the spread of healthcare-associated infections, barring long sleeves, traditional WCs, and wristwatches, among other attire.11 However, WCs may not be the culprit because a 2011 study reported that after 8 hours of wear, no differences were observed in bacterial colony counts or methicillin resistant Staphylococcus aureus (MRSA) growth from newly laundered short-sleeve scrubs versus infrequently laundered WCs.12 Furthermore, some British authors have raised concern that the hospital-mandated loss of the WC has lowered doctors’ recognizability among other healthcare workers.13 In our study, men and women wearing a business attire without a WC were most frequently identified as hospital administrators, whereas those in the same attire paired with a WC were identified as administrators less than 3% of the time. Particularly in the inpatient setting, where representatives from administrative departments such as billing, registration, or patient rela- tions are more likely to interact with patients, the WC seems to be a key factor in recognizability as a physician. In our investigation, the rate of identification as a surgeon was markedly higher for all tested types of attire when a WC was worn versus not worn. However, gender-based differences were found. Although women could boost their recogniz- ability as a surgeon for any given attire by wearing a WC, they were still more frequently identified as nonphysician healthcare workers than men in comparable attire. Mis- identification as a nurse or PA is a Pie charts depicting percentage rate of identification of role on healthcare team commonplace occurrence for many for each tested type of attire. Admin = hospital administrator; MA = medical female surgeons, particularly in assistant; PA = Physician Assistant; RN = Nurse; Surg = surgeon; WC = white coat. orthopaedics, where only 4% of the

August 2020, Vol 4, No 8 Effect of Orthopaedic Surgeon Attire

Table 2 Summary of Paired Comparisons of Surgeon Traits Based on Attire Comparison Competence Surgical Outcomes Physical Components Trustworthiness

Male scrubs 38 (17.2%) 25 (12.3%) 41 (20.2%) 28 (14.2%) Male scrubs with WC 75 (33.9%) 59 (28.9%) 41 (20.2%) 40 (20.3%) Same 108 (48.9%) 120 (58.8%) 121 (59.6%) 129 (65.5%) Adjusted P value 0.004 0.002 1 0.55 Male business 21 (9.5%) 17 (8.1%) 14 (6.9%) 18 (9.4%) Male business with WC 92 (41.8%) 82 (39.2%) 74 (36.6%) 50 (26.0%) Same 107 (48.6%) 110 (52.6%) 114 (56.4%) 124 (64.6%) Adjusted P value ,0.001 ,0.001 ,0.001 0.001 Female scrubs 24 (11.2%) 20 (9.8%) 33 (17.1%) 22 (11.1%) Female scrubs with WC 97 (45.3%) 68 (33.2%) 51 (26.4%) 45 (22.6%) Same 93 (43.5%) 117 (57.1%) 109 (56.5%) 132 (66.3%) Adjusted P value ,0.001 ,0.001 0.318 0.043 Female business 10 (4.8%) 7 (3.4%) 7 (3.4%) 10 (5.1%) Female business with WC 108 (52.2%) 97 (46.9%) 89 (43.8%) 60 (30.6%) Same 89 (43.0%) 103 (49.8%) 107 (52.7%) 126 (64.3%) Adjusted P value ,0.001 ,0.001 ,0.001 ,0.001 Female skirt 9 (4.3%) 5 (2.4%) 8 (4.1%) 6 (3.0%) Female skirt with WC 110 (53.1%) 86 (41.1%) 85 (43.4%) 64 (32.0%) Same 88 (42.5%) 118 (56.5%) 103 (52.6%) 130 (65.0%) Adjusted P value ,0.001 ,0.001 ,0.001 ,0.001 Male scrubs with WC 17 (8.2%) 8 (3.9%) 11 (5.6%) 6 (3.1%) Female scrubs with WC 34 (16.3%) 26 (12.8%) 20 (10.1%) 28 (14.4%) Same 157 (75.5%) 169 (83.3%) 167 (84.3%) 160 (82.5%) Adjusted P value 0.12 0.018 0.452 0.002 Male business with WC 22 (10.6%) 19 (9.5%) 23 (11.6%) 10 (5.1%) Female skirt with WC 26 (12.6%) 17 (8.5%) 16 (8.0%) 19 (9.6%) Same 159 (76.8%) 163 (81.9%) 160 (80.4%) 168 (85.3%) Adjusted P value 0.906 1 0.673 0.55 Male business with WC 19 (9.0%) 19 (9.3%) 24 (12.2%) 9 (4.6%) Female business with WC 27 (12.7%) 14 (6.9%) 9 (4.6%) 22 (11.3%) Same 166 (78.3%) 171 (83.8%) 163 (83.2%) 163 (84.0%) Adjusted P value 0.906 1 0.089 0.156 Female business with WC 22 (10.9%) 21 (10.3%) 25 (12.4%) 19 (9.6%) Female skirt with WC 29 (14.4%) 19 (9.3%) 14 (7.0%) 13 (6.6%) Same 151 (74.8%) 164 (80.4%) 162 (80.6%) 165 (83.8%) Adjusted P value 0.906 1 0.437 0.754 Female scrubs with WC 36 (16.7%) 43 (21.3%) 49 (24.3%) 23 (11.6%) Female skirt with WC 59 (27.3%) 34 (16.8%) 17 (8.4%) 20 (10.1%) Same 121 (56.0%) 125 (61.9%) 136 (67.3%) 156 (78.4%) Adjusted P value 0.12 1 ,0.001 0.76

WC = white coat Significant P values (,0.05) are in bold type.

AAOS members are women.2 This because patients may anchor to their leader of their surgical team. Fre- can cause strain and confusion in initial judgments and have difficulty quent instances of misidentification the physician-patient relationship treating the female surgeon as the and patient-expressed doubt about

8 Journal of the American Academy of Orthopaedic Surgeons Stephanie D. Goldstein, MD, et al

Table 3 Role Identification as a Surgeon for Matched Attire With and Without White Coats Attire White Coat No White Coat Adjusted P value

Female skirt 143 (61.4%) 19 (8.3%) ,0.001 Female business 138 (59.7%) 26 (11.2%) ,0.001 Female scrubs 134 (57.3%) 48 (20.9%) ,0.001 Male business 185 (79.4%) 42 (18.2%) ,0.001 Male scrubs 172 (73.8%) 78 (33.8%) ,0.001

Reported as N (%) who identified the picture as a surgeon. Significant P values (,0.05) are in bold type.

Table 4 Role Identification as a Surgeon for Matched Attire by Sex Attire Female Male Adjusted P value

Business with white coat 138 (59.7%) 185 (79.4%) ,0.001 Skirt with white coat 143 (61.4%) — ,0.001a Business, no white coat 26 (11.2%) 42 (18.2%) 0.252 Skirt, no white coat 19 (8.3%) — 0.025a Scrubs with white coat 134 (57.3%) 172 (73.8%) 0.003 Scrubs, no white coat 48 (20.9%) 78 (33.8%) 0.025

Reported as N (%) who identified the picture as a surgeon. Significant P values (,0.05) are in bold type. a P values from female skirt compared with male business counterpart their role as the surgeon are not only misidentification and may serve to would lower patient perceptions in frustrating for the surgeon but may support interventions for imposter skills more associated with men, dovetail with a phenomenon known syndrome targeted toward women in such as physical strength, but as “imposter syndrome,” in which a medicine. increase rankings of more “com- person feels persistently inadequate Orthopaedics has long held a rep- munal” skills, such as trustworthi- and underperforming, despite exter- utation as a surgical subspecialty ness. In our study, patients rated nal achievements and accomplish- reliant on, even dominated by, women in skirts markedly less likely ments to the contrary. An American physical strength.19 The relative to excel in the physical parts of College of Physicians position article dearth of women in the field may be surgery than women in scrubs, from 2018 identified imposter syn- related to the perception that too suggesting that dressing in unisex, drome as a notable challenge for much physical strength was nongendered attire gave female women in medicine and a contribu- required, as suggested by 74% of surgeons the outward appearance of tor to disproportionately low num- the RJOS members surveyed by more strength than if they wore a bers of women physicians achieving Rohde et al.2 Carnes et al have skirt. Feminine attire did not seem academic advancement and serving described that male-gendered ster- to give an advantage in appearing in leadership positions.14 Additional eotypes of “agentic” traits (e.g., more trustworthy in this study. works focusing on high-achieving assertiveness and technical prowess) Other recent orthopaedic-focused careers such as medicine and versus female-gendered stereotypes attire surveys have included STEM (science, technology, engi- of “communal” traits (e.g., empathy women in skirts, but as their only neering, and math) fields have and good listening skills) contribute “business attire” model, precluding demonstrated that women in high- to gaps in professional achievement comparison with other less overtly achieving fields are disproportion- between men and women in medi- feminine attire. Furthermore, al- ately affected by imposter syn- cine, academia, and research.10,20,21 though comparisons within each drome.15-18 Our data provide We hypothesized that feminine sex allowed a preferred attire to be credence to this often-experienced attire, such as skirts and dresses, identified, previous studies have not

August 2020, Vol 4, No 8 Effect of Orthopaedic Surgeon Attire published direct comparisons be- geons. Fox et al22 published a study not fully captured in this single center tween men and women orthopaedic of dermatology patients in Miami study, which reflects the environment surgeons.3-5 One previous study of that included both Caucasian and at a Midwestern large academic the importance of the orthopaedic black physician models in their institution. Unlike most other pub- doctors’ appearance from Scotland survey and noted respondents were lished attire studies, we did not include did not include any female models.6 more likely to prefer professional any models in casual attire. It has not Another important finding we attire for black physicians than been our experience that surgeons noted was that in the “comparison” white physicians and for women attempt to wear casual attire such as portion of our survey, the option of more than men. Even so, a reply to t-shirts and jeans to conduct regular “they seem the same” was chosen the editor lamented that the authors clinical duties. Furthermore, all previ- most frequently for all comparisons did not discuss the sex and racial ously cited studies that tested casual except for the three questions as- bias in more detail.23 The total attire found it to be consistently and sessing competence for female attire number of non-Caucasian ortho- overwhelmingly disliked by patients, a with and without a WC. There, the paedic surgeons has been increasing finding we deemed unnecessary to option with the model wearing a WC but is still just over 15% of prac- investigate again. was chosen most frequently. ticing orthopaedic surgeons based In conclusion, attire influences Although subtle, this suggests that on the 2018 AAOS Census Sur- patient perceptions of their ortho- the presence of a WC is more vey.24 Obese job candidates may be paedic surgeons. Female surgeons important for conferring competence less likely to be hired and assessed as who wear feminine business attire for women than for men. It also having less leadership skill than instead of scrubs may be rated less implies that the WC is a stronger their normal weight peers.25 The able to perform the physical work of marker for competence than the age of included models has varied in operating but are otherwise rated other three tested surgeon traits of recent studies, but it is reasonable to comparably with their male peers. By likelihood to give a good surgical think that patients may judge older magnitude of response, the WC was outcome, physical strength in the physicians to be more competent or more important for women than men operating room, or trustworthiness. be more likely to identify them as a in conferring competence. Surgeons Our study has several strengths. To senior member of the team. Future wearing WCs over any attire were our knowledge, it includes the largest studies that examine these factors deemed more competent and more number of respondents for any will help to further delineate bias in likely to give a good surgical outcome orthopaedic-specific attire study con- orthopaedics and identify means by than those without. Few other ducted in the United States. We re- which to combat these biases. gender-based differences in surgeon cruited patients from both sport Ours is one of the first orthopaedics- skill were identified. Men are more medicine and foot and ankle, neither oriented attire studies to span multiple readily identified as surgeons than subspecialty having previous published subspecialties and to include patients women when wearing a similar attire. attire studies. We recruited patients from both male and female ortho- On the basis of this study, men may from two subspecialties (Sports Medi- paedic surgeons. However, we omit- choose to don a WC to improve cine and Foot and Ankle) for which ted other orthopaedic subspecialty patient perceptions of competence there are not previously published patients who may have unique un- and ability to provide a good sur- attire studies, with a male and female derpinnings to their perceptions of gical outcome. Women orthopaedic surgeon from each subspecialty. surgeons. For example, many ortho- surgeons may experience a higher Our study has several limitations. paedic trauma patients do not first likelihood of being identified and One of the most critical is that our meet their orthopaedic surgeons in the judged as a competent surgeon if models were young, Caucasian, and outpatient setting, but rather are cared they wear a WC and viewed as more nonobese. We matched the age and for by whomever is on call that day. likely to excel in physical tasks in racial demographics and body habi- Alternatively, orthopaedic oncology the operating room if they don tus of our two models to allow the visits often involve discussion of sen- scrubs instead of business attire. attire to be the primary variable sitive topics that patients may prefer to under investigation. The authors do discuss with a surgeon dressed more References acknowledge that the influence of formally. Future studies spanning the age, race, and body habitus are likely breadth of subspecialties in ortho- 1. Petrilli CM, Saint S, Jennings JJ, et al: among the most important but least- paedics would be valuable. Understanding patient preference for physician attire: A cross-sectional observational study of investigated factors that may alter There are also likely regional dif- 10 academic medical centres in the USA. BMJ patient perceptions of their sur- ferences in attire standards that were Open 2018;8:e021239.

10 Journal of the American Academy of Orthopaedic Surgeons Stephanie D. Goldstein, MD, et al

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