New Delhi: “A good first impression can work wonders,” author JK Rowling writes in Harry Potter and the Order of the Phoenix. Conversely, a negative first impression can have long-lasting adverse repercussions. “First impressions” are based not only on the verbal content of the interaction, but also on appearance and demeanor and other nonverbal components. This is true in most social and professional settings, and healthcare is no exception. Doctors’ attire is a “vital part of the first impression the patient will develop of the doctor.” During the first clinical encounter, “the patient and the doctor not only exchange medical information about the treatment, but also build up trust and confidence for the future therapeutic relationship,” and the relationship between patients and physicians is “key to high-quality healthcare.”
Communication is central to the physician-patient relationship, and attire is “an influential source of nonverbal communication, especially in the absence of other information.” What a doctor wears can also be “an important factor in the degree of trust and confidence” among patients.
To shed further light on the role of physician attire in the medical setting, MPR interviewed Nathan Houchens, MD, Assistant Professor of Internal Medicine at the University of Michigan in Ann Arbor. Dr. Houchens is also Associate Chief of Medicine at the Veterans Affairs Ann Arbor Healthcare System as well as the Director of the University of Michigan Internal Medicine Residency Patient Safety and Quality Improvement Learning Program.
What interested you in this area of focus?
One of my areas of interest and career emphasis involves relationship-focused domains of medicine—communication skills, empathy, resilience, and patient safety.
The background for this line of research is that relationships and interpersonal communication are paramount for effective health outcomes, and the relationship between patients and physicians is key to high-quality healthcare. Multiple studies have shown the association between patient satisfaction with care and outcomes—the rates of engaging in preventive screenings, adherence, and even mortality. The concept is quite ancient, in fact, it goes all the way back to Hippocrates, who said that the physician “must be clean in person, well dressed, and anointed with sweet-smelling unguents.” And today, in the era of patient-centered care, it is especially important to build rapport and foster relationships with patients.
First impressions are an important part of the patient-physician relationship, because they can affect the quality of the relationship well beyond the initial encounter. Estimates vary, but previous research suggests that an impression can be formed in as little as 50 milliseconds.7 Another study found that judgments made after a 100-ms exposure were correlated with similar judgments that were made after longer exposure. The authors implied that the short exposure time was sufficient for participants to form an impression. Light travels very quickly and the first cues we get about another person are visual. So my colleagues and I wanted to take that seriously and see what patients do or do not appreciate the dress of clinicians.
What is the background of this particular study?
This study began with one of my colleagues, Christopher Petrilli, MD, here at the University of Michigan. In 2015, Dr. Petrilli and colleagues conducted the Targeting Attire to Improve Likelihood of Rapport (TAILOR) study; a systematic review regarding the role of physician attire in patient perceptions. The researchers analyzed 30 studies involving over 11,500 patients in 14 countries. The reviewed studies encompassed an array of different specialties, including general medicine, surgery, obstetrics, emergency departments, and hospital settings. They found a wide variety of perceptions among patients regarding physician attire, based on culture, tradition, patient expectations, geographic location, patient age, and context of care. For example, preference for formal attire and white coats was more prevalent among older patients and studies conducted in Europe and Asia. The level of education also made a difference. US respondents with a college degree were more likely to prefer formal attire with a white coat for a primary care physician, compared to those without a college degree.
What was the focus of your study and what were the findings?
We used a rigorous methodology from a previous study and surveyed 834 patients in 3 different specialties – dermatology, infectious disease, and neurology – using photographs of male or female physicians wearing various forms of attire. We then asked participants to rate how the physician’s attire affected perceptions in 5 domains: knowledge, trustworthiness, caring, being approachable, and feeling comfortable with the physician. Using these domains, we created a composite preference score, which was calculated as part of the primary outcome. Secondary outcomes included variation in preferences based on characteristics of the respondents and the context in which the care was delivered. The study was performed at 3 ambulatory clinics in a Swiss hospital.
We found that patients generally preferred physicians to be dressed in white scrubs with a white coat, while a business suit ranked lowest. But there was substantial variation among the respondents based on demographics and clinical settings. For example, respondents 65 years of age or older tended to report that physician dress was important to them and influenced their satisfaction with care. More respondents under age 65 preferred casual dress with a white coat, compared to those 65 years and older. On the other hand, in the emergency department setting, more respondents under age 65 preferred scrubs.
In the domains rated, formal attire with a white coat was rated highest for how knowledgeable a physician appeared, while white coats with white scrubs were rated highest for how trustworthy, caring, and approachable the physician appeared, and how comfortable the participant felt. The respondents in Switzerland seemed to reflect what is expected in their country, where the dress code of physicians is already relatively established and includes even the color of the scrubs under the white coat.
Similar research has been conducted in Japan. What we have seen from the results is that older patients generally prefer more formal attire with a white coat, especially in primary care and hospital settings, and that physician attire had a greater impact on older respondents. But even there, geographic differences are apparent, with formal attire and a white coat preferred in Western Japan, while in Eastern Japan, people prefer more casual attire with a white coat.
What do you think influences patients’ reactions and preferences regarding physician attire?
This is difficult to quantify. My guess, at least as it affects the US, is that storybooks and popular media – magazines, television shows, or movies – that portray physicians suggest what a doctor should look like to a substantial portion of the population. Hospital-based physicians are often wearing white coats with formal attire and a stethoscope, and surgeons and emergency room physicians tend to be portrayed in scrubs. This then becomes an expectation. But we did not research specifically where our respondents’ preferences came from or their rationale in how they came to their expectations.
What take-home messages does your research have?
The patient-physician relationship is critical to good health outcomes. Since physician attire is important to patient satisfaction, it is a modifiable way to potentially improve that relationship and improve patient safety and clinical outcomes.
A variety of factors, such as geography, care setting, patient age, and other variables play a role in patient preference of physician attire. As such, physicians and healthcare systems cannot take a “one size fits all” approach and must really tailor their dress code to those factors whenever possible.