Physician attire: physicians perspectives on attire in a community hospital setting among non-surgical specialties.

Background: Several studies have demonstrated a patient preference for physicians wearing a white coat associated with improved patient satisfaction. There are few studies on physicians' perceptions of attire mainly done in the outpatient and surgical specialties. Objective: Assess non-surgical physicians' perception of attire in the hospital and to identify if any difference in the choice of attire amongst generation X and millennial physicians.
Methods: We surveyed 86 physicians in the hospital with six sets of pictures of commonly worn physician attires in the hospital setting with a two-part questionnaire. Key
Results: Formal attire with a white coat was found to be most favored, followed by formal without a white coat. Casual attire without a white coat was the least preferred across the surveyed attributes. The results were similar in generation X and millennial physicians. Only 49% concordance was observed with what physicians preferred and what they wore.
Conclusion: Our study showed that physicians felt wearing a white coat was the best to convey specific attributes like honesty, confidence, professionalism, among others, similar to prior studies done in patients. However, less than half of the physicians surveyed themselves followed the preferred attire.

Introduction

Hippocrates promulgated the Hippocratic Oath that all physicians are familiar with. What we are less familiar with, is that he also advised physicians ‘must have a clean appearance, and wear good clothes, using a sweet-smelling scent this is pleasant when visiting the sick.’ [1] Over 2000 years later, with the evolution of medicine, the physician’s attire has also been continually evolving. Several previous studies have demonstrated that physician attire is essential to patients, their perception of the care they received, and their overall satisfaction [2-4]. The majority of studies on how patients perceive their physician’s attire concluded that the patients still preferred a more traditional dress style, as defined by the white coat. A recent cross-sectional observation study by Petrilli et al. [5] concluded that 53% of patients indicated that physician attire was essential to them during care.

However, few studies specifically explore the physician’s perception and preference for attire; most of which were studied more than two decades ago and focused predominantly on surgical specialties [6-8]. We believe that in these times, where patient satisfaction and rapport building is of increasing importance [9], attire plays a significant role. It is crucial to understand a hospital physician perceptions regarding the same. Our study aims to fill this gap by assessing inpatient physician perceptions of their attire and on specific patient-related attributes. Our study also sought to answer the question whether the younger generation of physicians would prefer more informal attire versus older generation (the so-called millennials [10] versus the generation X [11]) who may favor the more traditional attire.

Methods

The study was conducted at Rochester General Hospital, a 528-bed tertiary care hospital in Upstate New York from March–May 2018. Inclusion criteria for physicians were any physician, resident, or fellow in medicine subspecialty. Surgical specialties were excluded from our study.

We used a two-part survey questionnaire, as outlined in Table 1, along with a set of six pictures. Each picture paired a male and a female volunteer wearing six different outfits, as noted in Figure 1. The survey questionnaire and the pictures were randomly and individually handed to physicians who satisfied our inclusion criteria in the hospital along with an envelope. After the survey was completed, the questionnaire was placed into the envelope and handed back to the investigator.

Table 1.

Questionnaire handed to the physician.

Part 1Which is your primary specialty?Age: Sex:Based on the pictures provided to you that have been labeled 1 to 6, please select the picture which you feel MOST and which LEAST describes the following physician attributes as outlined below.
This physician	Most	Least
Appears trustworthy	1,2,3,4,5,6	1,2,3,4,5,6
Appears knowledgeable	1,2,3,4,5,6	1,2,3,4,5,6
Makes patient feel comfortable	1,2,3,4,5,6	1,2,3,4,5,6
Appears Professional	1,2,3,4,5,6	1,2,3,4,5,6
Feels easy to approach	1,2,3,4,5,6	1,2,3,4,5,6
Inspires confidence	1,2,3,4,5,6	1,2,3,4,5,6
Appears honest	1,2,3,4,5,6	1,2,3,4,5,6
Will strongly advocate for patient and patient care	1,2,3,4,5,6	1,2,3,4,5,6
Would pay attention what patients have to say	1,2,3,4,5,6	1,2,3,4,5,6
Would be considerate	1,2,3,4,5,6	1,2,3,4,5,6
Would keep the patient well informed	1,2,3,4,5,6	1,2,3,4,5,6

Figure 1.

Pictures handed with the surveys. 1. Scrubs with a white coat, 2. Scrubs without white coat. 3. Casual with a white coat. 4. Casual without white coat. 5.Formal with a white coat. 6. Formal without white coat.

2. Among the picture sets provided, which best describes your most frequently used attire?

3. Any further thoughts you would like to share?

Statistical analysis

The data were analyzed by using IBM SPSS software version 1.0.0.642. We used chi-square goodness of fit to analyze categorical variable with more than two levels, binomial test for categorical variables with two levels and chi-square test was used to detect a relationship between two or more categorical variables.

Results

We had a total of 86 responses. Of these, 66.3% were males, and 33.7% were female. The median age was 31 years. Photograph 5 (formal with a white coat) and photograph 6 (formal without a white coat) attires were the most and the second most favored attires across all attributes, respectively (Table 2). As per the chi-square goodness of fit model, there was a statistically significant difference between different attire groups in terms of their favorability and unfavourability across all attributes.

Table 2.

Attributes and favorability.

	Most trustworthy	Most knowledgeable	Most comfortable	Most professional	Most approachable	Most confident	Most honest	Most advocate	Most considerate	Most attentive	Most informed
Photograph 5	60% (51)	51.2% (43)	42.2% (35)	75.6% (62)	28.9% (24)	62.4% (53)	53.1% (43)	60.5% (49)	51.8% (43)	48.2% (40)	55.4% (46)
Photograph 6	24.7% (21)	33.3% (28)	36.1% (30)	18.3% (15)	30.1% (25)	22.4% (19)	27.2% (22)	16% (13)	26.5% (22)	32.5% (27)	22.9% (19)

Photograph 4 (casual without white coat) was the least favorite attire group across all attributes (Table 3)

Table 3.

Attributes and unfavorability.

	Least trustworthy	Least knowledgeable	Least comfortable	Least professional	Least approachable	Least confident	Least honest	Least advocate	Least considerate	Least attentive	Least informed
Photograph 4	83.3% (70)	80.5% (66)	68.3% (56)	88% (73)	43.2% (35)	82.7% (67)	72.8% (59)	72.8% (59)	70.4% (57)	69.1% (56)	73.8% (59)

Of respondents, 82.7% felt that physician’s attire matters; 86.4% felt that physician’s attire helps in creating a first impression; 44% thought that surgeons, ER physicians, and physicians who perform procedures should dress differently than primary care physicians, hospitalist, family practice physicians. At the same time, 40% of respondents did not have an opinion on this. Also, 67.5% thought that visibility or absence of piercings & tattoos influences a patient’s perception and 65% of the respondent believed that physicians’ fragrance influences the patient’s perception.

Between what physicians favored across different attributes and what they wore, surprisingly, there was on an average of only 48.85% concordance.

Attire group with a white coat (photographs 1, 3 and 5) was favored across most of the attributes except for comfort, approachability, and honesty where the favorability was similar across the two groups (Table 4).

Table 4.

Difference between white coat and non-white coat attires.

	Category	N	Observed proportion	Exact sig. (2-tailed)P value
Trustworthy	White coat	61	0.72	< 0.05
	No white coat	24	0.28
		85	1.00
Knowledge	White coat	52	0.62	< 0.05
	No white coat	32	0.38
		84	1.00
Comfortable	White coat	37	0.45	0.380
	No white coat	46	0.55
		83	1.00
Professional	White coat	65	0.79	< 0.05
	No white coat	17	0.21
		82	1.00
Approachable	White coat	42	0.51	1.000
	No white coat	41	0.49
		83	1.00
Confident	White coat	64	0.75	< 0.05
	No white coat	21	0.25
		85	1.00
Honesty	White coat	48	0.59	0.119
	No white coat	33	0.41
		81	1.00
Advocate	White coat	61	0.75	< 0.05
	No white coat	20	0.25
		81	1.00
Considerate	White coat	56	0.67	< 0.05
	No white coat	27	0.33
		83	1.00
Attention	White coat	51	0.61	< 0.05
	No white coat	32	0.39
		83	1.00
Informed	White coat	56	0.67	< 0.05
	No white coat	27	0.33

The formal attire group (photographs 5 and 6) was favored across all attributes except for approachability, where the favorability was similar.

There were no significant differences between males and females across different attributes. We grouped those aged 35 years or less as millennials and aged 36 years and above as generation X to identify if there was a difference in the choice of attire between these generations. There was no significant difference identified across all attributes between age groups (35 years or less than 35 years and more than 35 years). (Table 5)

Table 5.

Difference between millennials and generation X regarding white coat favorability.

Attribute	35 and below favoring white coat (Millenials)	36 and above favoring white coat (Generation X)	P value
Trustworthy	68.3% (41)	79.2% (19)	0.3
Knowledge	62.7% (37)	58.3% (14)	0.7
Comfort	55.2% (32)	58.3% (14)	0.7
Professionalism	77.2% (44)	83.3% (20)	0.5
Approachable	52.5% (31)	41.7% (10)	0.3
Confidence	75% (45)	75% (18)	1
Honesty	57.9% (33)	65.2% (15)	0.5
Advocate	77.6% (45)	69.6% (16)	0.4
Considerate	67.8% (40)	65.2% (15)	0.8
Attentive	61% (36)	60.9% (14)	0.9
Informed	65.5% (38)	70.8% (17)	0.6

Discussion

We believe that our study is the first of its kind to explore the hospital physician’s perception and preference for attire among non-surgical specialties. While previous studies in surgical specialties focused only on select characteristics such as trust and confidence [12,13], we explored eleven different patient attributes to see if specific attires better fit different patient attributes.

Our study results show that physicians overwhelmingly favored a formal attire with a white coat while a casual attire without a white coat was the least favored among all surveyed attributes. Wearing a white coat yielded similar results except when it came to be being perceived as approachable, comfortable, and honest with patients. We think that this is because not wearing a white coat is more relatable to a patient. Similar results favoring physicians in white coats were seen in studies which focused primarily on patient perception [2,3,5,13]

Given the change in dress attire in ‘traditional white-collar jobs’ across different service industries [14], we raised the question whether the younger generation of physicians would prefer more informal attire versus older generation who may favor the more traditional attire. Our study was able to show that the so-called ‘generation gap’ between the millennials and generation X at least does not exist when it comes to choosing a physician attire. This differs from a previous study that showed older physicians tend to prefer more traditional attire as compared to younger patients [6].

It was interesting to note that when we assessed a physician’s preferred attire, there was only 49% concordance. There are several reasons one could hypothesize for this discrepancy. Limited white coat availability issued by the institute (our hospital issues two white coats per year), poorly fitting white coat sizes, lack of hospital laundry services to have them cleaned and local weather are a few important ones that come to mind. There are also rising concerns about nosocomial infections associated with physician attire [15], which could be a contributing factor. Physicians could also be concerned that using a white coat may confuse them for a resident/intern or other ancillary services like pharmacy or nutritional services, which may be more of an issue in a teaching hospital. Recent graduates may also be trying to emulate their mentors or other influential personalities in the hospital who do not use a white coat.

Our study results must be interpreted in the context of certain limitations. It is a single-center study with a relatively small sample size. It is also important to note that the photographs showed young physicians, and it is unclear if the response would have been different if the physicians were older or of a different ethnic group.

Conclusion

Our study shows that ‘traditional’ formal attire with a white coat is the most favorable for patient interactions from a physician perspective. The findings are in line with patients’ perspective from previous studies. However, more than half of the physicians surveyed do not follow what they feel are better for patient interaction. Further studies are required to identify the barriers for this discordance and steps to overcome them.