Preferences of ophthalmic plastics patients and their caregivers toward the doctors' attire and initial communications: A tertiary eye care study.

PURPOSE: The aims of this study were to determine the acceptability levels of different styles of the doctors' dress and the expectations from the initial phases of physician-patient encounter.
METHODS: The study design was a cross-sectional descriptive type using the survey methodology. A survey based on a five-point questionnaire was performed on all consecutive patients or their caregivers, aged ≥15, visiting the ophthalmic plastics outpatient clinics at a tertiary eye care institute. The participants were shown three sets of photographs and were required to answer a questionnaire which consisted of five questions. Data collected include participant demographics and their preferences with regards to the physician's attire and initial communications.
RESULTS: A total of 300 consecutive responses were analyzed. The mean age of the participants was 37.2 years. Among the participants, 87.6% (263/300) and 90.3% (271/300) preferred a white coat for the male and female physicians, respectively (P < 0.001). The most common second preference was scrubs for both the males and female physicians. 92.3% (277/300) preferred the attire to have an identification display. The overwhelming majority of respondents (95.6%, 287/300) preferred the physicians to address them by their name and 98.6% (296/300) liked if their physicians smiled while addressing them.
CONCLUSIONS: White coat was the main preferred attire among respondents. Increased awareness of the patient's expectations plays a crucial role in enhancing their satisfaction.

Anthropologists view symbols as a means of expressing or reaffirming certain fundamental beliefs that a society holds.[1] White coats have symbolized healing and “what it means to be a physician.”[2] They were first documented to be used in operating rooms when the concept of antisepsis was born, as a means of preventing cross contaminations.[2] Subsequently, they were used in the laboratories and later in the hospitals. The color white was probably chosen since it represented life, purity, honesty, and superhuman attributes.[2] Few studies looked at the patients’ perceptions of the doctors’ attire and found that the physician's appearance played an important role in building trust, confidence, and empathy in a patient-physician relationship.[345] Although few studies have favored white coat,[4567] there are contrary opinions in the literature which showed that patients did not mind a semi-formal or smart casual attire.[891011] They questioned the hype around the white coat and its role in the patient-centric paradigm of care.[12] The current study surveyed the preferences of the ophthalmic patients and their caregivers with regards to doctors’ attire and initial communications in a patient-physician encounter.

Methods

Institutional review board approval was obtained before the start of this study. A cross-sectional descriptive study using the survey methodology was performed on all consecutive new patients or their caregivers, aged ≥15, visiting the ophthalmic plastics outpatient clinics at a tertiary eye care institute in South India in February 2015. Written consent was obtained. After the clinical encounter, the participants were then shown three sets of photographs and were required to answer a questionnaire which consisted of five questions. The first set of four photographs labeled as A–D, showed the male physician in different attires. Labels A–D represented casual dress, scrubs, formals, and with white coat, respectively [Fig. 1a–d]. The second set of four photographs showed the female physician in a similar manner [Fig. 2a–d]. The third set of three photographs showed different ways of identification card display; A–C representing midline display with a lanyard, at the breast pocket and the waist level, respectively [Fig. 3a–c]. The questionnaire had questions regarding the participants’ order of preferences for each of the attires shown, the use and penchant for the location of the identification data, their preferences for use of perfumes by the doctors and how they expect the physician to address them. For analysis, the participants were arbitrarily divided into three groups; 15–30 years, 31–50 and ≥51 years. The questionnaire is reflected in Table 1. Statistical significance was calculated using the Chi-square test and a P < 0.05 was considered significant.

Figure 1

The attire of male physician: (a) Casual dress, (b) scrubs, (c) formals, (d) white coat

Figure 2

The attire of the female physician: (a) Casual dress, (b) scrubs, (c) formals, (d) white coat

Figure 3

Locations for identification information: (a) Midline in front with a lanyard, (b) breast pocket, (c) waist level

Table 1

The questionnaire

Results

A total of 300 consecutive responses were analyzed. The mean age of the participants was 37.2 years (range: 15–84 years). 61% (183/300) of the respondents were males. The number of respondents and mean age in groups 15–30, 31–50 and ≥51 were 112 (mean age - 25.5 years), 136 (mean age - 37.74 years) and 52 (mean age – 61.2 years) respectively. Among the participants, 87.6% (263/300) and 90.3% (271/300) preferred a white coat for the male and female physicians respectively (P < 0.001). The most common second preference was scrubs for both the males and female physicians. If we analyze by age groups, although the 15–30 years had white coat as their first preference, their second preference was formals for men and scrubs for women. Participants in the age group ≥51 overwhelmingly preferred the white coat. 92.3% (277/300) preferred the attire to have an identification display, and more than half of this group (51.9%, 144/277) liked the information to be displayed midline in front with a lanyard. Although all age groups opted for the midline location as the first choice, the age group 31–50 chose it with a wide majority. Table 2 provides details of the participants’ responses with regards to doctors’ attire. The response to the use of perfumes by physicians did not have a clear winner and the views were divided between a yes, no, and does not matter. 95.6% (287/300) preferred the physicians to address them by their name and 64.8% (144/287) of this group preferred to be called by their first name. Overwhelming majority (98.6%, 296/300) liked if their physicians smiled while addressing them. Table 3 provides details of responses to issues relating to the initial interactions.

Table 2

Details of responses to doctor's attire

Table 3

Details of responses to initial encounters

Discussion

The current study examined the preferences with regards to the doctors’ attire and initial communications and found that it does matter to the patients and their caregivers. There is a preference for a uniform type of attire with an overwhelming majority preferring the white coat. The patients prefer display of identification information by the physician, and they like when the doctors’ call them with their first name and address them with a smile.

Kurihara et al.[7] conducted self-administered questionnaires in pharmacies with regards to doctors’ attire. On analysis of 491 complete responses, the factors that helped patients determine confidence in doctors in descending order were speech, reputation, and attire. The white coat was judged to be the most preferred attire followed by scrubs, although in age groups >50 years, scrubs were considered to be inappropriate. Rehman et al.[4] surveyed the internal medicine outpatient clinics (n = 400) and found that respondents significantly favored white coat (76.3%) followed by scrubs (10.2%) and business dress (8.8%). Respondents felt that the degree of trust and confidence and the patient's ability to share their social, sexual, and psychological problems is significantly more (P < 0.001) if the physicians are professionally dressed. Chung et al.[5] studied the perceived empathy in a patient-physician relationship using the “consultation and relational empathy” (CARE) score in 143 patients. The white coat received the highest scores in competency, trustworthiness, and preference of attire with significantly high CARE scores as compared with other attire. They concluded that the doctors’ attire plays an effective and crucial role in nonverbal communications and helps build confidence and trust in the patient-doctor relationship.

Contrary opinions exist in literature which does not support what can be called the “white coat hype.”[12] Lill and Wilkinson[8] performed a survey that included both inpatients and outpatients from a wide range of medical and surgical specialties at a tertiary care hospital. The patients in their study preferred the doctors to wear semi-formal attire call them by their first name and greet them with a smile. The respondents were more comfortable with conservative items of clothing like long sleeves; however, less conservative items were also acceptable. Gosling[9] analyzed 451 responses to the question “what is your ideal doctor like?” 153 adolescents specifically commented on the doctor's dress and among them 53% preferred casual dress and 47% favored smartly dressed doctors. Many respondents (number not mentioned) stated that their physicians should be “clean and not smelly!” Aitken et al.[11] studied 427 responses of the patient and their relatives in orthopedic outpatient clinics. The most preferred doctors’ attire was smart casuals with “bare below the elbow” dress code. The impression of cleanliness and good hygiene were more desirable than the appearance of the attire. Majority of the participants favored compassion, politeness, and knowledge as more important attributes than the attire. The concepts of “bare below the elbows” and the role of “white coats and ties” in the spread of nosocomial infections have attracted good attention.[1112131415] Some believe that while white coat may be perceived favorably for inspiring trust and confidence in a patient, it is a symbol of authority and may reflect a paternalistic view of the physician.[12]

Petrilli et al.[16] conducted a systematic review to examine the influence of physician attire on patient's perceptions. They included thirty studies from 14 countries, which met the eligibility criteria and assessed them using the Downs and Black scale risk of bias scale. About 70% of the studies reported positive influence of physician attire on patient's perceptions. Formal attire and white coats were preferred in 60% of the studies, and most of these were from Europe and Asia. Nearly 57% of the studies involving procedural specialties and 80% involving intensive care or emergency settings showed no preference for the attire. About 25% of the studies that surveyed patients following a clinical encounter showed preferences for the physician's attire. In comparison, the current study was conducted in tertiary specialty settings and the patients were surveyed following a clinical encounter and yet, there was an overwhelming preference for the white coat.

The limitations of such surveys including the current study are geographical and cultural influences on the attire and that the responses are first impressions rather than an actual encounter. In addition, the age, attractiveness, and clothing style of the physician may also influence the responses. We could have chosen more traditional attire in the formals category for the female physician. This omission could have tilted the choice more in favor of white coat although it can be argued that studying an urban population and the general geographical social norms could not have influenced it to an extent as demonstrated in the results.

Conclusions

The ways in which a doctor dresses and initially communicates are important for the patients and their caregivers. Increased awareness of the patient's expectations plays a crucial role in enhancing their satisfaction. However, it must also be noted that professional behaviors and patient-centric care are much more important.

Financial support and sponsorship

Dr. Mohammad Javed Ali receives royalties from Springer for his textbook, “Principles and Practice of Lacrimal Surgery”. Other authors have no financial disclosures.

Conflicts of interest

There are no conflicts of interest.