It is time for a dress code in psychiatry

August 2020

EDITORIAL: It is time for a dress code in psychiatry

Aug
2020
Vol. 32. No. 3
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

Mary K. Morreale, MD

The interaction between patients and psychiatrists (as well as other physicians) is a complex matter to which our profession pays much attention. We teach medical students and residents how to listen, communicate, and interpret the patient’s posture, gestures, facial expressions, and eye contact. As part of an assessment of our patients’ appearance, we note both their grooming and attire. However, we do not always talk about our own appearance and dress. Many professions and institutions have dress codes to address the appearance of their employees. Historically, physicians were expected to wear a white coat, but this is often no longer the case, especially for psychiatrists and physicians in outpatient clinics and private facilities. At times, we have seen resistance to the suggestion of a dress code among our colleagues and residents. We have heard physicians arguing that formal dress and/or a white coat can be a barrier between them and their patients, especially patients from a lower socioeconomic class. Should there be some type of dress code in psychiatry? Do we know whether a more formal attire truly creates a barrier between us and our patients?

A dress code, in general terms, is a set of written or spoken rules about what clothing one should wear in specific settings or situations. There are different dress codes for various institutions and businesses. Dress codes may reflect social class, culture (non-Western cultures have their own dress codes), tradition, religious affiliation, profession, allegiance to an institution, or appearance at a special occasion such as a wedding or funeral.

As noted by Gjerdingen et al,1 physician appearance has been of interest for centuries. Even Hippocrates, in his comments on physician behavior, noted that a physician should “be clean in person, well-dressed, and anointed with sweet-smelling unguents.”2 In the United States, a number of studies conducted over the last several decades have addressed physician appearance and both patient and physician preferences for physician dress. For example, in a study of 404 patients, residents, and staff physicians regarding attitudes toward various aspects of physician appearance, participants’ positive responses were associated with dress items such as a shirt and tie, dress shoes, dresses, and nylons, and for physician-identifying items such as a white coat and name tag.1 In contrast, negative responses were associated with items such as blue jeans, scrubs, athletic clogs, and sport socks. In a study by Dunn et al,3 200 patients in Boston and San Francisco were interviewed about their preferences regarding physician appearance. Sixty-five percent of participants believed physicians should wear a white coat, 37% believed physicians should wear neckties, and 34% believed female physicians should wear dresses or skirts (this study, conducted during the 1980s, did not reflect the reality of professional women increasingly wearing pants). Dunn et al3 also reported that 27% of participants believed physicians should not wear tennis shoes and 52% believed physicians should not wear blue jeans. Finally, in a cross-sectional study of 4,062 patients at 10 academic medical centers, 53% agreed that how their physician dressed was important to them, and 36% agreed with the statement that physician attire influenced how happy they were with the care they received.4 Most (56%) participants had either neutral or negative responses to physicians wearing casual attire when seeing patients on weekends.

Findings regarding physician attire are similar in other Western countries. In Scotland, McKinstry and Wang5 assessed the preferences of 475 patients using photographs of different styles of dress for both male and female physicians. Patients favored a more formal approach to dress, with male physicians wearing a suit and tie and female physicians wearing a white coat. The majority of patients (64%) thought that the way a physician dressed was very important or quite important, and 41% reported that they would have more confidence in the ability of a physician based on his/her appearance. In a study of 168 patients who were treated at a family medicine clinic in Israel, approximately half (52%) preferred their physician to be dressed in a white coat.6 In another study of 834 patients seeking care at a dermatology, infectious disease, or neurology clinic in Switzerland, patients preferred their physicians to be dressed in white scrubs with a white coat.7 Finally, an interesting note from a small study conducted in Brazil: Most patients felt uncomfortable with shorts, facial piercings, and tattoos in male physicians, and with facial piercings, crop tops, shorts, and tattoos in female physicians.8 Although the perception of appropriate physician attire varied across countries, it is important to note that customary formal attire was preferred.

In his commentary/review on the value of using an old dress code in the new millennium, Brandt9 concluded “It appears that the attire of the health care provider is important to patients across all lines of population and geography.… A neat, clean appearance, however, is more important than attire.” As we noted, there are certain variations in dress codes in different settings, such as not wearing a tie in the psychiatric emergency room. Nevertheless, we agree with Gjerdingen et al1 that “In the physician-patient interaction, the physician’s appearance is a key symbol that not only identifies the individual as a physician, but also defines certain characteristics of the physician. The clear, carefully dressed physician might give the message, ‘This is an important event, and I took time to prepare for it,’ while the unkempt, careless appearing physician can be perceived as unskilled and uncaring.” Although, as Petrilli et al4 remarked, physician attire cannot replace excellent clinical care, it may influence how patients perceive care, and how willing they are to trust their doctors. Similarly, Dunn et al10 felt that attire and etiquette are not substitutes for good clinical skills, although they play a role in the development of the physician–patient relationship.

One may wonder how physician attire is viewed within psychiatry, because the studies discussed above did not include the opinions of psychiatrists or patients seeking psychiatric care, and we were unable to locate any studies that specifically address this issue. We believe that psychiatry should follow the findings from other specialties, because our patients should not be treated differently and therefore stigmatized. The aforementioned hearsay argument about formal dress creating a barrier between psychiatrists and socioeconomically disadvantaged patients does not hold water unless proven in studies. We may counter that, through our own experience, the majority of patients, regardless of socioeconomic class, comment positively on the proper attire of their psychiatrists, including us (one of us wears a tie and jacket or suit). We agree with Brandt,9 who states that attire is important because everything in the physician–patient interaction is important. If we adhere to the Hippocratic Oath, why shouldn’t we follow Hippocrates’s suggestion regarding our appearance? As we pay increasing attention to professionalism, shouldn’t we also attend to professional dress?

Thus, we argue that a dress code should be sanctioned and reinforced in psychiatry—as is done in other specialties—especially in outpatient and consultation-liaison settings, and should also be required for residents during training.

CORRESPONDENCE

Richard Balon, MD
Department of Psychiatry and Behavioral Neurosciences and Anesthesiology
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA

E-MAIL
[email protected]

REFERENCES

1. Gjerdingen DK, Simpson DE, Titus SL. Patients’ and physicians’ attitudes regarding the physician’s professional appearance. Arch Int Medicine. 1987;147:1209-1212. 2. Jones WHS. Hippocrates. Volume
2. Cambridge, MA: Harvard University Press; 1923:311-312.
3. Dunn JJ, Lee TH, Percelay JM, et al. Patient and house officer attitudes on physician attire and etiquette. JAMA. 1987;257:65-68.
4. Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open. 2018;8:e021239. doi: 10.1136/ bmjopen-2017-021239.
5. McKinstry B, Wang JX. Putting on the style: what patients think of the way their doctor dresses. Br J Gen Pract. 1991;41:270, 275-278.
6. Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract. 1998;15: 391-397.
7. Zollinger M, Houchens N, Chopra V, et al. Understanding patient preference for physician attire in ambulatory clinics: a cross-sectional observational study. BMJ Open. 2019;9:e026009. doi: 10.1136/ bmjopen-2018-026009.
8. Hortense AB, Martinez JB. A little more on the appearance of doctors. Rev Assoc Med Bras (1992). 2014;60:2.
9. Brandt LJ. On the value of an old dress code in the new millennium. Arch Intern Med. 2003;163:1277-1281.
10. Dunn JJ, Lee TH, Goldman L. Patient and house officer attitudes on physician attire and etiquette. JAMA. 1987;257:2032.