Back in 2002, two Stanford dermatologists published a study in which they sent a questionnaire to a week’s worth of patients, asking them their preferences for how medical providers should dress. The study covered relatively new ground. Two of the four references were the 1970s best-sellers Dress for Success and The Woman’s Dress for Success Book.
The study also uncovered strong preferences: Patients preferred a white coat, dress shoes, and a “traditional” hairstyle, and abhorred sandals, blue jeans, and when men had earrings or “long hair/ponytail.”
Subsequent studies were more scientific. A 2005 emergency department trial used a “100-mm visual analog scale” and received approval from an Institutional Review Board, which deemed that the outfits in the trial were not heinous enough to put patients at risk.
The scale is a 10-cm line between paired qualities like “unprofessional” and “professional” on which raters make a mark. This technique allows traits to be assessed with millimeter precision. In this case, the scale precisely showed that patients don’t care what their doctor wears.
Clothing studies proliferated around the world in a sartorial arms race between doctors who like scrubs and those who like formal professional clothes. A 2014 meta-analysis tried to make sense of the morass by combining data from 30 studies and over 11,000 patients, concluding, weakly, that people tend to prefer formal clothes, although “perceptions of attire are influenced by age, locale, setting, and context of care.”
Team Scrubs was not ready to give up. Weren’t a white coat and tie, those hated symbols of formality, also seldom-washed bastions of disease? More scholarly ink was spilled, including one test of the germ theory, in which neckties were soiled with a solution of 100 million bacteria per milliliter and then draped across unsuspecting mannequins.
Unsurprisingly, some bacteria could be cultured off the mannequins.
When the microbial dust settled, a meta-analysis found the evidence of ties causing infection weak. A randomized trial in Colorado showed that by the end of the workday, newly washed scrubs have just as many contaminants as seldom-washed white coats.
A lack of evidence is seldom a barrier to administrators, and in 2007 the British National Health Service (NHS) forbade its providers from wearing a white coat or long sleeves. The NHS guidelines, updated in April 2020, still prohibit most employees from wearing these items, although they now allow people with a religious objection to wear ¾-length sleeves.
The updated NHS guideline is a 16-page document, complete with a table of contents and four appendices. The rules come off as arbitrary. It forbids employees from wearing more than two identification tags, or earrings other than studs. Stop touching me with your dangly earrings, Karen!
One thing these guidelines miss is that clothing serves a function in hospitals beyond physician-patient interactions. In Guns, Germs and Steel, Jared Diamond explains that specialized forms of dress arose when tribes grew to the size in which people often encountered strangers. Hawaiian chiefs, for example, had cloaks made of tens of thousands of feathers, allowing them to be recognized immediately, even when far from home.
White coats may be blasé by comparison, but medical organizations are like these societies in that they create a lot of interactions with strangers. Not only do patients need to identify team members, but hospital employees often interact with other employees they don’t know. Whether it’s a nephrologist on the ward or a pharmacy tech checking a clinic’s medications, a lot of medicine occurs away from one’s own department.
Having uniforms for providers has obvious advantages over ID badges. Uniforms can be assessed at a distance, in 360 degrees and without that awkward moment when people realize you’re checking their name tag.
Furthermore, there is a seldom acknowledged undercurrent to many clothing studies. Dermatologists, some of the more stylish physicians, created a study lauding dressing to impress. ER physicians, typically practical, in-the-trenches types, ran a study that showed scrubs are just fine. There’s a pattern in these studies that falls short of the loftiest ideals of medical research.
Ideally, trials should be done because an investigator doesn’t know the answer to something. Few attire scientists seem to be so impartial. Instead, they seem to be producing objective data that support how they already dress.
In this respect, the explosion in these studies may have more to do with the centralization of medicine, with the growing role of administrators like those in the NHS, than with scientific curiosity.
When a dermatologist dresses nicely, it may comfort the patient because the doctor is demonstrating that they know the importance of appearance — and consequently will take the patient’s cosmesis seriously. For an injured patient in the ER, scrubs may be comforting because the patient knows the doctor is not afraid to get dirty.
It would be a shame if physicians weren’t allowed to influence their interactions by making choices about their appearance. If clothing research is what is needed to convince administrators to maintain this freedom, then maybe all the trouble is worth the effort.
Christopher Watson, MD, is a radiation oncologist and can be reached at his self-titled site, Chris Watson.
This post appeared on KevinMD.