American College of Physicians: Internal Medicine — Doctors for Adults ®


An evidence-based approach to getting dressed

How resident clothing affects patients, colleagues, success

From the April ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

Flip on the TV or even open a newspaper lately, and you might get the impression that medical residents are going about their jobs in shockingly inappropriate attire—men in rumpled shirts and five o'clock shadow and women wearing tiny skirts and stilettos.

Television characters, a recent column in the New York Times, and a feature on the Today show have made physician attire a focus of public attention.

But the issue is nothing new, according to Pamela A. Rowland, MD, a behavioral scientist at Dartmouth Medical School who has studied physician dress.

"If you go back and read Hippocrates, he talks about dress. In the history of medicine in the U.S., they talk about British physicians being very neat and clean in comparison. If you go back through history, you'll see that what physicians wear has always been an issue," she said.

Surgeon Donald Gann, MD, illustrates how patients will focus on the one item of clothing that doesn't fit

Surgeon Donald Gann, MD, illustrates how patients will focus on the one item of clothing that doesn't fit. After changing from waterproof boots to tied leather shoes, his professional ranking rose to first place across all age groups studied.

Dr. Rowland realized how important physicians' clothing is when she was conducting research on patient confidence and found physician dress to be a major variable. In one study, Dr. Rowland and her colleagues had patients rate doctors on their professionalism based on photographs.

The results came as a surprise to her. "The youngest physician in our national study was the second-most professional. Age wasn't the factor. It was what he was wearing," she said.

The doctors rated most professional-looking wore a tie, a jacket (either a suit jacket or a lab coat), and tied leather shoes if they were men. They also had belts and shoes of matching color leather, no jewelry except for a wedding band, and carried some tools of the trade—pens, stethoscopes, eyeglasses.

For women, shoulder-length or shorter hair, a jacket, a skirt and minimal jewelry rated highest on the professionalism scale.

It's not that patients are expecting their physicians to have perfect style sense, said Dr. Rowland. But any variation from the conservative standard draws some small amount of attention.

"You don't want what you're wearing to be noticed. You want people to focus on your face and your quality of care," she said.

Contrary to Dr. Rowland's results, a new study of 1,116 ob/gyn patients, published in February, found that women are concentrating on quality of care more than clothing. The researchers had practicing physicians dress in business clothes, casual attire or scrubs, and then surveyed their patients about overall satisfaction. They found "no difference in the mean overall satisfaction score among the three physician attire groups," according to the study, published in the American Journal of Obstetrics & Gynecology.

Dr. Rowland was not convinced by the data, which study authors admitted could have been influenced by many factors, including patients' tendency to evaluate doctors favorably right after their encounter. "Although I'm delighted that they are interested in the topic, too many variables in the study were not independent, controlled or reported," she said.

Peer pressure

Other physicians, as well as patients, take note of apparel, Dr. Rowland discovered in her studies. She looked at oral board exams, and found a relationship between dress and scores. "If you looked different from everybody else that was taking the exam that day, it puts a little bit of doubt when you walk into the room that you're not taking it as seriously," she said.

As if patient confidence and board scores weren't enough pressure on your outfit, it could affect malpractice claims as well. Dr. Rowland doesn't have any empirical evidence on that issue, but she does have one telling anecdote.

A patient suing over a post-surgical error said that she knew her surgeon wasn't focused on her because he came to her room in jeans, a T-shirt and athletic shoes. "Every other physician said he probably came and checked her and then went into the locker room and changed into scrubs, but what the jury saw was that he wasn't focused on her 100%," said Dr. Rowland.

The story confirms the impressions of other physicians. "I wouldn't be surprised if patients were more forgiving to doctors who in earnest made an error but look more like doctors than like hippies," said Mark Lema, MD, an anesthesiologist who has written about physician dress.

But perhaps, like hippies, concern about dress is something that dwindles away over generations? Not so, said Dr. Rowland. She studied 18- to 22-year-old patients and found that they preferred conservatively dressed doctors about as much as older patients.

Geographic location also had very little impact, to the researchers' surprise. "We really thought we might get regional differences, that California might be more casual," Dr. Rowland said.

Despite agreement on the importance of dress, doctors were divided over the current state of the situation. Dr. Rowland thinks formality is on the rise among residents, thanks to dress codes and the 80-hour rule.

"I think the hardest thing before was residents getting enough time to take care of themselves—get their hair cut, keep clean. The work hour change has made it easier," she said.

Douglas Bacon, MD, a course director at the Mayo Clinic, worries that residents are getting more casual all the time, but he is pleased by the changes he sees every so often on an individual basis. "We had a resident who gave the appearance of not being the brightest light bulb in the pack. He was a weightlifter and he used to come in wearing a muscle shirt in the summer, and he wondered why nobody respected him."

After some time, the resident began wearing a jacket and tie. "All of a sudden, the attending staff in both his specialty and others started treating him a little differently," Dr. Bacon said.

Grandma knows best

Muscle shirts aside, the most commonly cited issues with resident dress were fairly minor—failure to wear name tags, shoes without socks, fake nails.

At Christiana Care Health System in Wilmington, Del. a few residents have found a way to avoid fashion dilemmas altogether.

"Some residents do not have a lot of disposable income to purchase a full seven day a week rotating wardrobe which is more expensive than buying scrubs, or just finding them someplace in the hospital," said Allen R. Friedland, FACP, Christiana Care's medicine/pediatrics program director.

Those scrubs are the usual baggy kind, not the figure-flattering versions depicted on "Grey's Anatomy," he noted. "I think the fitted lab coats that are on the TV programs are not something any hospital wants to pay extra money for," Dr. Friedland said.

To those residents who do want to look like celebrities, physicians warned that it is possible to go too far in the dressy direction as well. At the Mayo Clinic, residents vie to be the best-dressed, but as Dr. Lema advises, "sometimes you can look too slick. No starched shirts with French cuffs or a contrasting collar with a $75 tie."

Dr. Rowland agreed that she has found a certain amount of "nerd factor" to be helpful for young doctors.

With such a range of fashion advice and criticism, it can make just putting on clothes in the morning another frustration for busy residents.

But one medical student blogger had a simple solution to the dress dilemma. "I take note of what female physicians wear, and I always ask myself, 'Would I wear this to visit my grandma?'"


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