Are We Dressed for Success?

Print

Written By

James Lee, Pharm.D., BCACP
Shubha Bhat, Pharm.D., BCACP

Reviewed By

Dawn Fuke, Pharm.D., BCPS
Maria Pruchnicki, Pharm.D., BCPS

Citation

Petrilli CM, Mack M, Petrilli JJ, et al. Understanding the role of physician attire on patient perceptions: a systematic review of the literature – targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015;5: e:006578

Every health professional takes an oath to serve patients. To fulfill this covenant, patient trust must be earned. Without trust, patients are unlikely to share sensitive, personal information, hindering our ability to provide optimal care. Gaining trust is influenced by many factors. What influence does attire have on patients’ perceptions of their healthcare providers?

 

Several studies have examined the impact of attire on patient perceptions.  One study found that children favored healthcare providers who wore white coats; yet another study found children who had frequent encounters with the healthcare system were more likely to favor physicians in informal attire.1,2 In the United Kingdom, a ban on white coats, ties, and long-sleeved shirts in government-run hospitals was instituted to combat the spread of hospital-acquired infections.3,4 The reaction to the ban has been mixed.  While governing authorities have stood firm on public health grounds, public and professional organizations have voiced concerns about the loss of credibility and identifiability.5 Public health concerns as well as clinical and psychological consequences — such as white coat hypertension —have led some to question the need for clinicians to wear formal attire and a white coat. However, a consensus about what the appropriate attire for physicians and health care workers should be has not yet emerged.

 

The TAILOR (Targeting Attire to Improve Likelihood of Rapport) study sought, in a systematic review of the available literature, to determine the influence of physician attire on patient perceptions, confidence, and satisfaction.6 Using specific vocabulary consisting of synonyms for clothing, the TAILOR investigators searched MEDLINE, Embase, Biosis Previews, and Conference Proceedings Index for English and non-English full-text papers, abstracts, and posters. Additional studies were identified through manual searches of bibliographies. Studies must have included participants at least 18 years old, physician attire as a variable, reporting of patient-centered outcomes (satisfaction, perception, trust, attitude, comfort), and an evaluation of the impact of attire on the patient-centered outcomes. Studies involving exclusively pediatric or psychiatric patient populations were excluded. Tools such as the Downs and Black Scale and calculation of Cohen's k statistic were used to rate study bias and inter-rater reliability. Due to the heterogeneity of study methods and outcomes reported within the included studies, the investigators intentionally avoided performing a formal meta-analysis. To better compare outcomes, standardized definitions and classifications (Table 1) were used by the TAILOR investigators.

 

Table 1 – Standardized Definitions and Classifications

Term

Definition

Physician Attire

Personal or hospital-issued clothing, with or without a white coat

Formal Attire

Male physicians: Collared shirt, tie and slacks

Female physicians:  blouse (with or without blazer), skirt or suit pants

Casual Attire

Not “physician” or “formal” attire; polo, shirts and blue jeans

Context of care

Location of care delivery (i.e., intensive care unit, urgent care, hospital, or clinic)

Acute care

Emergency department, intensive care unit, or urgent care. All others considered “non-acute”

Clinical Encounter

Face to face interaction between physician and patient

Medicine Populations

Disciplines including family medicine, internal medicine, private practice clinics, inpatient medicine wards

Procedural Studies

Disciplines including dermatology, orthopedics, obstetrics/gynecology, podiatry and surgery

Words affiliated with positive perceptions

Satisfaction, professionalism, competence, comfort, trust, confidence, empathy, authoritative, scientific, knowledgeable, approachable, easy to talk to, friendly, courteous, honest, caring, respect, kind, spent enough time, humorous, sympathetic, polite, clean, tidy, responsible, concerned, ability to answer questions, took problems seriously

Words affiliated with negative perceptions

Scruffy, aloof, unkempt, untidy, unpleasant, relaxed, intimidating, impolite, rushed

 

Of 1,040 studies identified, 30 were included in the analysis. The majority (22) were published within the previous ten years. Only eight of the included studies were associated with higher methodological quality, with high inter-rater agreement for study quality (k=0.87). A third of the studies were performed in the United States, with the remaining from 14 other countries spanning all continents. In total, 11,533 patients were included in the analysis.  Approximately 67% were female. Seven studies included patients with a high school or college level education. Patients who sought care in medical specialties in both acute and ambulatory settings were included (See Table 1). Patient preference regarding physician attire was captured using pictures of models in various attire styles, written descriptions of attire styles, questionnaires, and surveys. Some studies also collected feedback before or following face-to-face clinical encounters.

 

Overall, 21 of 30 (70%) of the studies reported preferences for a specific attire style or documented a correlation between physician attire and positive patient perception. Eighteen studies (60%) indicated that patients preferred formal attire with white coats. However, age, geographic variations, and medical specialty influenced patient preferences (See Table 2).

 

Table 2 – Attire Preferences of Patients

(+) Formal Attire

(+) Scrubs or No Specific Attire

  • Patients > 40 years
  • Patients in non-US countries, particularly Asian countries
  • Younger patients
  • United States
  • Acute care settings
  • Procedural disciplines

 

When provided with a written description or visual example of different types of physician attire, patients tended to prefer formal/traditional attire. When verbally asked about attire preferences following a clinical encounter, patients were less likely to voice a preference.

 

The TAILOR investigators conclude that patients harbor conscious and subconscious biases that associate formal attire and white coats with trust and confidence; yet, cultural and societal expectations of physicians likely play a significant role in influencing patient preference. Regardless of the attire worn, the authors believe that physician competence would ultimately influence patients’ trust in their health care providers.

 

Some strengths of the study include the scope of the literature search, rigorous inclusion and exclusion criteria, and the use of validated tools to control for study bias and inter-rater reliability. Furthermore, the authors – appropriately — examined the impact of culture, tradition, and care setting on patient preferences. Limitations include the observational nature and limited quality of the included studies, which prevents any assessment of causality and limits the authors to descriptive assessments only. Additionally, the heterogeneity of study designs and reported outcomes introduces potential bias and prevents comparisons between studies. The authors acknowledge that more rigorously designed studies are needed.   Moreover, the authors encouraged individual institutions to conduct their own studies to assess the influence of attire on patient perceptions in specific patient populations.

 

Although the TAILOR investigators only evaluated patient perceptions of physicians, the study findings can likely be generalized to pharmacists. In a time when pharmacists are actively seeking provider status and routinely interact directly with patients, the question of attire and its influence on patient-provider relationships should draw increased attention. The authors suggest provider competence is the overriding factor that ultimately influences patients’ trust in health care providers. Yet several studies have noted that patients affiliate white coats and formal attire with competency and trustworthiness.7,8

 

A formal dress code and the “white coat” are essential elements of the professionalization process for student pharmacists.9,10  Students are often expected to wear white coats to lab-related courses and, in patient care settings, students are expected to dress formally. Additionally, the length of the white coat is used to distinguish between students/trainees and more senior practitioners. While there seems to be support for traditional attire among older practitioners, generational differences on what constitutes professional attire exist.11   Furthermore, the patient populations to whom we provide care are increasingly diverse. The definition of “professional” attire will continue to evolve.  In some patient care contexts, “informal” attire may engender trust and respect while “traditional” attire may be perceived as cold and authoritarian. Ultimately, pharmacists must understand the needs and preferences of their patients by developing cultural awareness.  Cultural competence also means dressing appropriately.

 

What do you think? As pharmacists pursue a broader scope of patient care responsibilities, is it time to embrace a broader definition of professional attire? Or should pharmacy continue to rigidly adhere to the traditional definition of professional dress passed down through the generations? Are we dressed for success?

 

Comments

7

I appreciate the commentary. It does seem anecdotally that other millennials like me would be more accomodating of non-traditional apparel (as they are with other social/political concepts). It's always interesting to see that confirmed with data. I am all for ditching the white coat if that makes clinicians more human and approachable. However, I would think downgrading from shirt/tie to no tie (or other more casual attire) could harm integration with our practices to some degree. In clinics where they are new to pharmacists, I'm not sure I'd want to give off more 'you're different from us' vibe than we already do.
Lucas G Hill's picture

Training in a family medicine residency, I got used to dressing "business casual" in the outpatient setting. Anecdotally, I feel that it allowed me to forge a more personal connection with my patients. I suspect this is why I never saw a social worker or other counselor dressed in formal attire. Accentuating the "power distance" between my patient and myself strikes me as the wrong choice when I want to encourage an open and honest dialogue. It seems likely that patient perceptions, such as those evaluated in this systematic review, are informed by prior experience. As fewer clinicians dress formally, fewer patients may prefer it. I would be more interested to see a randomized trial comparing the information about non-adherence gained by providers with and without white coats. Another related issue would be how we introduce ourselves. "Hello, I'm Dr. Hill, the pharmacist." vs "Hi, I'm Lucas, the pharmacist." I prefer the latter.

I echo your comments Lucas! I too trained in FQHCs that always endorsed business casual. The occassional provider would wear a coat but most times this was a "specialist" (or in my case at times...just plain cold!) Some older providers still wear coats. I have found in the 3 clinics I have worked in, this more casual approach is appreciated by patients. Many of the patients I work with come from other countries and have a real fear or distrust of medical care and thus the providers. The intimiadting lab coat is usually met with resistance with these patients. I do however ask my students to wear their lab coats while in clinic to identify themseleves as someone in training. I have always referred to myself as "Stefanie" vs. "Dr. Nigro" to patients and I never once have felt that they treat me with less respect, etc. Interesting topic to think about!

The point that resonated with me the most was the one that states "Cultural competence also means dressing appropriately." I don't believe that there can be a one-size-fits-all approach to pharmacist professional attire as preferences and norms tend to vary by geographic location, practice site, and patient population. Many institutions employ a dress code that can allow for variations on the formality of the attire and can be adapted to the culture of that clinic/institution. It would be interesting to get a sense of how the public perceives pharmacist professional attire and whether the findings vary by region or patient population. The professional attire issue is an interesting one to remain cognizant of as we continue to evolve as a profession.

Good points about cultural competence and dressing appropriately to make a connection with patients. I always wonder how neatness plays into this as well. You can have two people wearing 'business casual' attire that appear on different ends of the spectrum depending on how they put themselves together (wrinkle-free vs. messy; shirt tucked vs. untucked, etc.). I was glad to see the authors included this concept in their standard definitions. Words associated with negative impressions were scruffy, unkempt, untidy.

I agree with many of the previous comments. I have always preferred a "business casual" approach for the same anecdotal reasons; I feel like it allows me to connect with my patients in a more honest and meaningful way. However, I've always wondered if part of that is because I live in Portland, OR v. somewhere on the East Coast?

I recently joined the Commissioned Corps of the USPHS and I noted a difference with my patients, even the ones I've known for years. If a white coat is intimidating, what about a military-style uniform? Some patients reacted positively, others not. There are many sites, IHS in particular, that discourage officers from wearing the uniform because it intimidates patients. But then there's also a long history of Native dissatisfaction with the Federal Government (rightly so). So that's a complex issue to say the least. I would love to see a study comparing patient perceptions of clinicians in uniform vs. civilian clothes! I do echo earlier comments that Family Medicine, regardless of which coast you are on, is generally a more casual atmosphere with regards to dress than other practice settings, or at least that's been my experience. Interesting review and commentary.

Pages