Not that long ago members of my division were given an update on the University’s dress code. Despite the fact that no sane person would pick me as the best dressed of any group to which I belong, I believe that I am largely on the proper side of the dress code. So I did not read it thoroughly. Hearsay had it we were told that jeans were not allowed and scrubs were only to be worn with an accompanying white coat, something I have not worn since a red pen broke in my pocket during residency. These edicts reminded me of similar dress code demands handed down to us residents while I was in residency, specifically a prohibition of jeans with holes and Spandex. Both of these policies, I believe, most physicians can live with, and Spandex is only one small step above nudity and may not be acceptable anywhere other than while in a gym or on a bike. Although nudity can be fun, and I know several attractive physicians, wearing the birthday suit at work would likely be frowned upon by most patients and their loved ones in the hospital, despite the entertainment that would be provided to some 5 to 10 year olds and other childish persons. I will venture to say that most kids of any age probably do not care what you are wearing when you are shoving a stick down their gullet or a plastic funnel into one of their ears. But let’s agree that nudity is unprofessional for physicians in a hospital or clinic, despite what you do at home.
So what is our university’s dress code for physicians? There is a dress code for physicians that appears to be an abridged version of the hospital’s dress code for all employees. The latter document is lengthy, mostly straightforward, and contains a large number of prohibitions and limitations. No “trendy pants of extreme style.” Perhaps that is open to interpretation; maybe you just know it when you see it, like pornography.1 Nothing “odor-ridden.” That one is a little tougher to adhere to at all times for a bike commuter such as myself. I guess I could change outside, but that would be unpleasant and could win me a citation for indecent exposure. Perhaps not so good for a pediatrician, especially if cited in the parking lot of a children’s hospital. Badges are not to be worn below the bottom of the sternum or on a lanyard, despite ubiquitous hospital-issue lanyards that put badges at the level of the umbilicus or thereabouts. This issue is delightfully complicated in that we work for a university in a hospital that is not university owned; the corporation that owns the hospital also does not have a written dress code specifically for physicians or a prohibition on lanyards, but they do want something called “maximum personal hygiene.” So that is what MPH stands for. No fish-net stockings. At least not visibly displayed. Body odor? Not on company time. No velour anywhere ever.2 The penalty for such offensive offenses can include termination (hopefully just your job, although that is not specified).
What does the American Academy of Pediatrics say regarding physician attire? Nothing. The American Medical Association (AMA)? Nothing, although there was an unfruitful movement in the AMA in 2009 to adopt a dress code for physicians. Oh well. They say a lot about more important topics.
Spandex: not so good. White coat: good? There is a surprising amount of published literature on the subject, which shows somewhat of a worldwide preference for doctors to wear white coats, at least where it has been investigated. A study of patients in Saudi Arabia this year found that 85% preferred that their physician wear a white coat, much more so than even traditional Saudi attire (9.7%).3 Also this year, in Italy, where fashion is somewhat of a big deal (headquarters of Gucci, Prada, etc), a study of physician appearance indicated that Italian patients have a need for a “sober professional image of their physician,” which includes attention to detail in personal grooming, conservative dress, and a white coat.4 Probably sober in another way as well, I would bet. The Japanese also prefer that physicians wear a white coat,5 specifically a clean one. Picky, picky. Iranians like doctors in white coats as well.6 Hawaiians apparently do not like their doctors to wear casual attire to an “extreme,” that is they do not take kindly to physicians in shorts and slippers, despite whatever they may be wearing.7 Speaking of flip-flops, some find them to be unacceptable when visiting the White House, even if you are a national champion and you were invited.8 I do not envision that particular conundrum vexing me. That same study in Hawaii also showed that patients preferred physicians wearing white coats. The Australians chime in: white coats are still revered by some,9 even if the doctors do not want to wear them.10 It is hot there, after all.11 Veterans in South Carolina are “significantly” more likely to share details of their social, sexual, and psychological problems with a doctor wearing professional attire, including a white coat.12 Perhaps a reason not to wear one, that is if you want to keep your patient histories brief. Or if you just do not want to hear about it.
Many of these studies found that demeanor was as important as attire, or that a white coat gave an impression of trustworthiness or some such. A noble pursuit, no doubt, especially when people do not always like our advice (it could just be me).
Other aspects of physician attire? There is a article written by Nair without mention of body hair preferences.13 Smiling is important in New Zealand,14 where people are nice.15 Facial piercings? Not so good.16 And these unsubstantiated tidbits from the operating room: (1) The scrub size you wore in your younger days may no longer be appropriate, and (2) let’s keep that thong covered up.
That is all very instructive, but what does it mean for pediatricians in the United States? Pediatricians may be held somewhat apart from others in the name of placating the children, and some of us probably use that as an excuse for not wearing a white coat. I just find it unbearably hot, and being hot does not help in my efforts to maintain a professional appearance, which does not include profuse sweating. And there is that pesky body odor requirement. Wiki.answers.com has this to say on the subject of pediatrician attire: “girls should wear a nice dress, or a nice blouse with pants/skirt. You should dress nice but not going to a wedding nice. Men should wear dress pants and a nice shirt.” Case closed. There is a link to wedding, if you do not know what that means. Pediatric ophthalmologists in Iowa City are free not to wear a white coat,17 but other pediatric ophthalmologists should.18 Hmmm, I see. One of the authors for the latter article is named Coats. Conflict of interest? In Canada, white coats do not scare children, at least as evidenced by their stated preference for their physician’s appearance when presented with photos of various ensembles.19 It might be a little different if that same photo showed that same person with a sinister countenance or holding a syringe and a needle. And Canadians are accustomed to white stuff, it frequently falls from the sky.20 I will also say that some kids just do not like anybody but their parents. Teenagers may be an exception to that, so watch out. Canadian children do not, however, like doctors in standard precaution attire.21 I do not blame them. That brings up images of alien abduction, needles, and probing. In a pediatric emergency department in Cincinnati in 1995, parents stated a preference for their children’s doctors to wear white coats but not tennis shoes.22 No word from the kids. Some kids in Stony Brook, New York do not care what their male pediatricians wear, but they like their female pediatricians in a blouse and skirt.23 A study of kids in the United Kingdom in 1994 had this to say: “Children regard formally dressed doctors as competent but not friendly; they regard casual dress as friendly but not competent.”24 What is your choice? Competent or friendly? Perhaps where you stand on that spectrum has already been established. Although it is never been studied, you cannot go wrong with a “Queen of the Pediatricians” T-shirt, be you male or female.25 They make ties as well.
Lurking in the shadows is the thought that white coats and ties can serve as fomites or vectors. Those are scary words (or names for your cats), but is this a well-founded fear? The germ theory is well-founded, and I believe is why some say we need to wash our hands in the hospital, silly as that may sound. We could just throw some well-worn ties into surgical wounds and see what happens. I will ask the institutional review board and our surgeons. In lieu of that, let’s go to the literature. In Malaysia, doctors’ ties frequently are contaminated with methicillin-resistant Staphylococcus aureus26 (maybe some other kind of degree of higher learning). It seems clear that doctors’ ties are full of bacteria,27–29 posing a theoretical danger to patients, although linking such contamination to hospital-acquired infection is difficult. This risk was what motivated the AMA dress code initiative, which was abandoned because of a lack of evidence of a problem. Adam Jones, an English urologist, had this to say about surgeon attire and infection in 2008: “Of course many people believe that any theoretical infection threat from ties, watches or surgeons’ clothing is merely a smoke screen for the extraordinarily high bed-occupancy rates in a push to maintain targets.”30 But I’m not smart enough to understand that. We probably ought to gown up with standard precaution attire for every patient, even if it scares them.
A rose is a rose, but what is a clown without the big shoes and a red nose? Still a clown, I say, but perception is an important component of human interaction, and you may save yourself some time if you are well dressed, or at least be deemed trustworthy. Most of the referenced studies on white coats involved showing photos to patients or parents, who chose how they would prefer their doctor to look. Perhaps those choices were mainly influenced by what a doctor is supposed to look like. Be that as it may, hospitalists such as myself are frequently in the position of seeing unfamiliar patients, who may appreciate the ability to identify their in-house doctor easily, especially when the doctors change frequently. Keeping up appearances is not always bad, unless you won the lottery and your money is all gone. Just back it up with some good old medical knowledge.31 If you are in doubt about what to wear, my wife or mother can certainly help you out. And don’t do as I do, do as I say.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
REFERENCES AND WHATNOT
- 1.↵I know it when I see it. Available at: http://en.wikipedia.org/wiki/I_know_it_when_I_see_it Accessed July 1, 2012.
- 2.↵I made that up. I just don’t like it. But I am no fashion consultant.
- Najafi M,
- Khoshdel A,
- Kheiri S
- 8.↵NU’s lacrosse team sparks flip-flop flap at White House. USA Today. July 19, 2005. Available at: www.usatoday.com/news/nation/2005-07-19-flip-flops_x.htm Accessed July 1, 2012.
- 11.↵I cannot prove that.
- Lill MM,
- Wilkinson TJ
- 15.↵Rumor and conjecture.
- 20.↵Snow, I mean, but this is an unsubstantiated generalization about Canada.
- Barrett TG,
- Booth IW
- 25.↵Queen of the pediatricians T-shirts & shirts. Available at: www.zazzle.com/queen+of+the+pediatricians+tshirts. Accessed July 1, 2012.
- 31.↵Medicine. Available at: http://en.wikipedia.org/wiki/Medicine. Accessed July 1, 2012.
- 32.Random study I do not understand: Su G, Brøndum RF, Ma P, Guldbrandtsen B, Aamand GP, Lund MS. Comparison of genomic predictions using medium-density (~ 54,000) and high-density (~ 777,000) single nucleotide polymorphism marker panels in Nordic Holstein and Red Dairy Cattle populations. J Dairy Sci. 2012;95(8):4657–4665.
- Copyright © 2012 by the American Academy of Pediatrics