Physicians’ Attire Influences Patients’ Perceptions in the Urban Outpatient Orthopaedic Surgery Setting

Regulations adopted in the United Kingdom have effectively prohibited white coats along with watches, ties, or long sleeves owing to the potential, yet unproven risk of infection transmission [3, 4, 11, 21]. Studies have shown that patient awareness of the “bare below the elbows” policy might influence their preferences for physicians’ attire [3, 4, 7, 24]. The topic of physicians’ attire has increased in popularity with increasing regulations to prevent infection, with a concomitant increased value placed on patients’ reviews of their experience in the hospital or clinic. Study results in various other settings diverge in their recommendations, therefore increasing the difficulty in adapting meaningful changes to daily practice [1, 2, 3, 5, 12, 13, 15, 16, 17, 18, 19, 21, 22, 23], and to our knowledge, no previous studies have examined the influence of physicians’ attire in the urban orthopaedic surgery setting in the United States. For this reason we sought to determine what influence, if any, our attire has on patients’ perceptions and which outfit was preferred in this population.

This study has several limitations. The study was conducted at one institution in an urban setting with relatively young patients, which is a potentially important limitation as previous studies have established the influence of location, culture, and age on patients’ preferences [16, 22]. For several reasons, location may have an effect on respondents’ preferences. In the United Kingdom, for example, the “bare below the elbows” policy might substantially alter patients’ perceptions of their physician’s attire [1, 3]. Geographic location also might influence patients’ preferences owing to various cultural or even climate-related reasons. Our study was conducted in the northeast United States and therefore may not be generalizable to the global population. With young patients, previous work has established their preference for more casual attire compared with older patients who prefer a more formal dress code [4, 12, 15]. In this cohort, adult patients in the orthopaedic clinic were examined and their reported results may be influenced by setting, healthcare system, and specialty. The pictured physicians in this study were young and white, which could have influenced respondents’ preferences for their attire. The choice to use white physicians was predicated on the methods of prior studies, the majority of which showed only white physicians pictured in various attire [1, 12, 15, 16]. This not only eliminated confounding variables, but facilitated comparisons between this study and those in other settings. Furthermore, four outfits were chosen based on historical studies on this topic, however, there were numerous combinations of clothing (such as white coat over scrubs), which were not included and might have performed better than the tested attire. Finally, the use of a Likert scale has inherent limitations as an ordinal scale that subsequently is represented as numeric comparisons. The five-level scale was compressed to three levels as this enabled statistical analysis as categorical variables, the results of which are more relatable and logical (like, neutral, dislike as opposed to numerical “levels”). As discussed previously, we believe p values actually would have been even better with continuous analysis given the various assumptions imposed on this type of test. The survey was designed for this study and therefore was not previously validated, however these questions are similar to those used in previous research on physician attire and we believe are meaningful and comparable to these precedent studies [1, 12, 15, 16, 23]. For this study an effect size of substantial was set at a difference of 0.75, moderate at 0.5, and small at 0.25. Future research is needed to investigate the preferences of patients in a suburban or rural orthopaedic setting to elucidate the generalizability of our results regarding patients in an orthopaedic setting. Moreover, the influence of “bare below the elbow” guidelines enforced in the United Kingdom on patients in the United States has not been established and may further influence patients’ perceptions and preferences.

We found that patients at an urban outpatient setting showed a moderate preference for male surgeons with a white coat and female surgeons with either a white coat or scrubs. In terms of patients’ confidence in their physician, no difference was observed between scrubs and white coat over business attire. Respondents’ predilections for the white coat are consistent with published results, which denote the coat as symbolic for a clean, competent, and professional surgeon [12, 16, 23]. Although pediatric and psychiatric patients may accept, or even prefer casual dress, it was disliked in the orthopaedic surgery setting [5, 8]. Previous studies have established a “white coat effect” where patients experience reflexive hypertension and anxiety when examined by a doctor wearing a white coat [14, 20, 25, 26]. The results of our study showing a preference for a white coat and scrubs, taken in light of prior research on physician attire, are likely explained by the white coat’s associated authority, professionalism, and ability to identify the physician. In a surgical field, however, scrubs likely convey the same attributes with a potentially added benefit of improved hygiene and avoidance of the “white coat effect”.

Two investigations indicate a growing preference for scrubs and “smart casual” attire, which are not only perceived as hygienic in conforming with the bare below the elbows regulations, but further serve to identify the treating physician [1, 13]. Some authors [2, 3] have postulated that while variations may exist from specialty to specialty, the unifying factor in clothing preferences is simply a uniform or outfit that conforms to patients’ preconceived image of a doctor. Therefore, it is not surprising that the white coat and scrubs were nearly equally well received in our study, as both outfits are seen in hospitals, television shows, and movies as attire which identifies the treating physician. Finally, patient age has been implicated as an important factor in determining preference for physicians’ attire. Younger respondents accept more casual attire and scrubs compared with older patients who favor more formal dress [4, 12, 15]. Authors point to a subconscious notion of how physicians should appear as the driving factor in determining preference, and that preconceived image of a physician varies with the age of the patient and evolves with time [1, 2, 15]. The majority of our study population was between 35 to 54 years old, however 80% of the patients surveyed were younger than 55 years. Owing to the relatively young cohort of respondents, it is not surprising that scrubs performed nearly equally as well as the white coat given the aforementioned evidence that younger patients are likely to favor scrubs and less formal attire.

Many factors of the doctor-patient interaction influence the first impression and cannot be replicated without a face-to-face encounter. Regardless of the physician’s appearance, attributes such as demeanor, empathy, tone of voice, hygiene, and even smiling, will shape a patient’s perception of his or her doctor [1, 3, 6, 17, 23]. One of the proven and changeable factors that contribute to the first impression and overall patient trust and confidence is the attire of the physician. In the urban orthopaedic outpatient setting, we observed modest preferences for the white coat and scrubs, which inspire patient confidence and are favored compared with formal or casual attire. Importantly, attire does influence how our patients perceive their physicians’ character and abilities, therefore future endeavors might examine broader influences on the patient-physician relationship such as race, sex, and professionalism.