EDITOR’S CORRESPONDENCE Results. The survey was offered to 501 family members, RESEARCH LETTER and 337 (67%) agreed to participate. Participants were predominantly female (68%); white (78%); college or uni- Physician Attire in the Intensive Care Unit versity educated (60%); and immediate family members and Patient Family Perceptions of Physician (79%) of primarily male (59%), severely ill (mean Professional Characteristics APACHE II [Acute Physiology And Chronic Health Evalu- ation II] score of 24) patients admitted because of respi- hysician attire is a modifiable factor that has been ratory failure (31%). The patient characteristics of fam- demonstrated to influence the patient-physician ily members who responded to the survey were similar relationship.1-6 However, patient-physician in- to those who did not. The median time from patient ICU P admission to family members being offered the survey teractions in the intensive care unit (ICU) differ from other health care settings. Patients admitted to the ICU typi- was 3 days (interquartile range, 1-5 days). cally do not have a preexisting long-term relationship with A majority of participants reported that wearing an easy their ICU physician, and therefore trust needs to be es- to read name tag (77%), neat grooming (65%), and pro- tablished over a short time frame.7 The severity of pa- fessional dress (59%) were important when first meet- tient illness frequently results in the active participation ing a family member’s ICU physician, while a minority of family as surrogate decision makers, complicating the felt that physician sex (3%), race (3%), age (10%), ab- patient-physician relationship. The high acuity of the ICU sence of visible tattoos (30%) and piercings (39%), or makes for a wide range of attires worn, from scrubs to wearing a white coat (32%) were important. suits. We therefore conducted a survey in 3 ICUs to ex- Conversely, when selecting their preferred physician amine ICU patient family perceptions and preferences for from a panel of pictures, respondents strongly favored physician attire. physicians’ wearing traditional attire with the white coat (Figure). Physicians in traditional dress were seen as most knowledgeable and most honest. Physicians wearing See also page 406 and either scrubs or a white coat were seen as most com- Invited Commentary at end of letter petent to perform a life-saving procedure and most caring. When participants were asked to select the best physician overall, they selected physicians wearing tra- Methods. We performed a cross-sectional survey of fam- ditional attire with a white coat (52%), followed by ily members of consecutive patients admitted to 3 medical- scrubs (24%), suit (13%), and casual attire (11%) Ͻ surgical ICUs (Calgary, Alberta, Canada) during the pe- (P .001 for test of proportions). Survey responses riod November 1, 2010, to October 31, 2011, to assess were similar across participant age, sex, race, relation- self-expressed preference for physician attire. Partici- ship to patient, and education. pants were asked to rate the importance of 10 physician- Comment. In our study, a majority of respondents in- related factors (age, sex, race, neat grooming, facial pierc- dicated that it was important for physicians to be neatly ings, visible tattoos, professional dress, white coat, visible groomed, be professionally dressed, and wear visible name name tag, and overall first impression) using a 5-point tags, but not necessarily a white coat. Despite these self- Likert scale and to select the best physician from pho- reported preferences, when patients’ families selected their tograph panels of 4 physicians (eAppendix; http://www preferred physician from a panel of photographs, respon- .jamainternalmed.com). Photograph panels were gener- dents strongly favored physicians wearing traditional at- ated from a stratified random of 32 photographs of 8 tire with the white coat. Traditional attire was associ- physician models to ensure that each panel contained a ated with perceptions of knowledge, honesty, and photograph of each study attire (traditional white coat, providing best overall care. Physicians wearing scrubs were scrubs, suit, and casual attire), 2 male and 2 female mod- a second choice among participants and were perceived els, and 1 model of each visible race (white, black, In- to be caring and competent to perform a lifesaving dian, and Asian). Binomial confidence intervals were com- procedure. puted for observed categorical responses and compared Our study provides the first description of ICU pa- using ␹2 tests. All analyses were performed with SAS ver- tient family perceptions and preferences of physician at- sion 9.2 (SAS Institute Inc) statistical software. The study tire. Our results highlight 3 key observations. First, in was approved by the Conjoint Health Research Ethics contradiction to the theory that patients have less pref- Board. erence for traditional attire in the acute care setting,8 we JAMA INTERN MED/ VOL 173 (NO. 6), MAR 25, 2013 WWW.JAMAINTERNALMED.COM 465 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Suit Scrubs White coat Most Knowledgeable Casual Most Competent Most Honest Most Caring Best Overall 0 10 20 30 40 50 60 70 Respondents, % Figure. Family selection of the best physician to care for a family member admitted to the intensive care unit from photograph panels of physicians in 4 different dress styles. Data are presented as point estimates with 95% confidence intervals. observed a family preference for physicians wearing white sis. Study concept and design: Au, Khandwala, and Stelfox. coats or scrubs. Second, the 2 most preferred attires in Acquisition of data: Au. Analysis and interpretation of data: our study, white coat and scrubs, share the commonal- Au, Khandwala, and Stelfox. Drafting of the manuscript: ity of being a uniform, which may help patients and fami- Au, Khandwala, and Stelfox. Critical revision of the manu- lies identify their health care providers. Third, we af- script for important intellectual content: Au and Stelfox. firmed that regardless of dress, professionalism, neat Statistical analysis: Khandwala. Obtained funding: Stelfox. grooming, and a clear name tag are perceived as a req- Administrative, technical, and material support: Stelfox. uisite by patient families. These results suggest that while Study supervision: Stelfox. families may not express preferences for how physi- Conflict of Interest Disclosures: None reported. cians dress, there may be subconscious associations with Funding/Support: This project was supported by an es- well-recognized physician uniforms including white coats tablishment grant from Alberta Innovates. Dr Stelfox is and scrubs. Given the importance of effective commu- supported by a New Investigator Award from the Cana- nication in the ICU, physicians may want to consider that dian Institutes of Health Research and a Population Health their attire could influence family rapport, trust, and con- Investigator Award from Alberta Innovates. fidence. Role of the Sponsors: The funding sources had no role in the design, conduct, or reporting of this study. Selena Au, MD, FRCPC Previous Presentation: This study was presented at the Farah Khandwala, MSc 41st Critical Care Congress; February 4, 2012; Hous- Henry T. Stelfox, MD, PhD, FRCPC ton, Texas. Online-Only Material: The eAppendix is available at http: Published Online: February 18, 2013. doi:10.1001 //www.jamainternalmed.com. /jamainternmed.2013.2732 Additional Contributions: We thank Barbara Artiuch, Author Affiliations: Department of Critical Care Medi- MD, and Jessalyn Holidinsky, BSc, for their help with ad- cine (Drs Au and Stelfox) and Departments of Medicine ministering the survey instrument and Matthew James, & Community Health Sciences and Institute for Public MD, PhD, for his comments on earlier versions of the Health (Dr Stelfox), University of Calgary, and Alberta manuscript. Health Services–Calgary Zone (Drs Au and Stelfox and Ms Khandwala), Calgary, Alberta, Canada. 1. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? effect Correspondence: Dr Stelfox, Teaching Research & Well- of doctor’s attire on the trust and confidence of patients. Am J Med. 2005; 118(11):1279-1286. ness Building, University of Calgary, 3280 Hospital Dr NW, 2. Dunn JJ, Lee TH, Percelay JM, Fitz JG, Goldman L. Patient and house officer Calgary, AB T2N 4Z6, Canada ([email protected]). attitudes on physician attire and etiquette. JAMA. 1987;257(1):65-68. Author Contributions: All authors had full access to all 3. Gallagher J, Waldron Lynch F, Stack J, Barragry J. Dress and address: patient preferences regarding doctor’s style of dress and patient interaction. Ir Med J. of the data in the study and take responsibility for the 2008;101(7):211-213. integrity of the data and the accuracy of the data analy- 4. Lill MM, Wilkinson TJ. Judging a book by its cover: descriptive survey of pa- JAMA INTERN MED/ VOL 173 (NO. 6), MAR 25, 2013 WWW.JAMAINTERNALMED.COM 466 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 tients’ preferences for doctors’ appearance and mode of address. BMJ. 2005; Also interesting were the study’s findings that more 331(7531):1524-1527. 5. Gooden BR, Smith MJ, Tattersall SJ, Stockler MR. Hospitalised patients’ views than 10% of respondents selected the image of the per- on doctors and white coats. Med J Aust. 2001;175(4):219-222. son wearing jeans as the best physician and that a busi- 6. Keenum AJ, Wallace LS, Stevens AR. Patients’ attitudes regarding physical char- ness suit was not preferable to more casual attire. It seems acteristics of family practice physicians. South Med J. 2003;96(12):1190-1194. 7. Azoulay E, Sprung CL. Family-physician interactions in the intensive care unit. unlikely that any participants truly preferred jeans over Crit Care Med. 2004;32(11):2323-2328. more formal or identifying attire. Other factors that var- 8. Li SF, Haber M. Patient attitudes toward emergency physician attire.