Do we need a dress code?

2 Comments

Consider the purpose for setting up a standardized look before enforcing a uniform policy.

Dear Director,


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I’ve been concerned about how some of my team dresses and am considering implementing a dress code for our docs.  What do you think about that?

Just like we form an impression of the patient and their likely diagnosis within a brief timeframe, the patient (and their family) is forming their first impressions about us.  Our appearance and attitude early in the evaluation can influence all aspects of the visit, ranging from length of stay to patient satisfaction.  After all, if your patient trusts you, they’re more likely to understand why they don’t need a CT scan for their mild closed head injury or antibiotics for their URI. Since early in 20th century, the white coat has been a symbol of the physician’s professionalism, which inspires trust and respect.  It also helps to identify us in the ED among the variety of scrubs that are often worn.

When I think about formalizing a dress code, I have to ask myself why do we need this and what do I hope it will accomplish? Do I have individual providers who look disheveled or unprofessional (or may benefit from a conversation in my office) or do I want to standardize our appearance and elevate the professionalism of the department?  I used to work with a guy who wore bright orange clogs, so in a field historically known for its cowboy behavior, how much individuality should we allow?


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Hospital Policy

Patients often have a hard time identifying who is who in the department.  Is it a tech, nurse or respiratory therapist?  Universally, patients agree, that we should all have our badges on with our roles identified.  (This is also a Joint Commission requirement).  Hospitals will frequently have roles where scrubs are color-coded—our nurses are dark blue, our techs are maroon, our respiratory therapists are red.  This is just part of the hospital dress code that hospitals have in their employee manual.  There will also likely be a section on hair color and style, nails, shoes and likely something about piercings and tattoos (more on these later). Some of this is based on safety while some of this is developed to create an environment that inspires trust from the patients and translates into positive patient perceptions and higher patient satisfaction.   As you develop your own policy, it is important to be aware of the hospital policy and consider being as consistent as possible.

Patient Satisfaction

Our professionalism, which includes our appearance, communication skills and bedside manner, inspire our patients to trust us and can be linked to patient satisfaction.  Patients have a perception of what a physician should wear, and just like with other aspects of our job, sometimes it is about fulfilling the perception.  In a recent study, 53% of patients surveyed said how their doctor dresses was important to them and 36% said that physician attire influenced how happy they were with the care they received.[1]


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Safety

Many hospital policies are put in place to protect the employee or the patient.  Open toe shoes are prohibited because they don’t protect you from bodily fluids.  Long hair should be pulled up when doing procedures so it doesn’t contaminate your field. Policies on nails, particularly acrylic nails and polish, are in place to reduce the risk of bacteria transmission.  It turns out that acrylic nails don’t get adequately cleaned with alcohol-based gels.

Internationally, some facilities have banned neckties because of the risk of spreading bacteria (as well as the inherent risk of getting strangled by a patient). Others are taking it a step further by implementing a “bare below the elbows” policy (clothing, jewelry, watches, artificial nails) to also reduce infection spread.  Although there are studies showing that physician’s neckties often are colonized by bacteria that can cause hospital-acquired infections, to date, there is no clear evidence that our clothing is impacting disease transmission, as compared to how good hand hygiene can reduce hospital acquired infections.  Some authors have suggested that physicians are psychologically more attentive to hand hygiene when they wear white coats and formal attire.[1] By the time you’ve completed residency, you probably have a pretty good understanding of these issues, but we may find ourselves educating our scribes on these safety policies.

White coats and scrubs

I’m a fan of wearing a white coat.  It holds my stethoscope, pens and reference books.  I think it helps with my “doctor look” and generally helps define the providers in my department and differentiate us from the nursing staff. It turns out in study after study, patients generally like seeing physicians in a white coat as well.  It inspires trust and confidence, two traits I hope my patients see in me.  What clothes you wear may depend on your actual job and how likely you are to get bloody (are you in a trauma center, suturing a lot of lacs, etc).  I had a colleague who had his male docs wear ties because he thought it improved their professional appearance and would result in higher patient satisfaction.  The department’s patient sat was consistently above the 98th percentile, but I honestly don’t know how much was correlated to the ties.  In older research, patients preferred formal attire, with a white coat.  But it turns out, in more recent studies, patients have subtle differences in their preferences based on the type of doc they’re seeing and where in the hospital the encounter takes place.[1] Overall, patients still prefer that docs wear white coats, but in the ED, scrubs with or without a white coat is completely acceptable from the patient’s point of view as compared to your hospital, non-surgical specialist, where patients prefer formal attire with a white coat.[1] I’ve also seen facilities have a more formal dress code for day and evening shifts and allow scrubs at night.  My clinical uniform is typically a white coat with khaki pants and scrub top, but I think if you’re wearing scrubs, they should match (top and bottoms), and the physicians should have a universal color just like the nurses and techs.

Sweatshirts and other casual tops

Most residencies I know have a lot of swag that their docs wear both in and out of the hospital.  In many places, a fleece may be acceptable in the clinical area.  There’s a fine line between wearing a sweatshirt and looking too casual versus wearing a light jacket with the hospital logo on it.

Tattoos and Piercings

I trained in a pretty conservative environment in the 1990s.  Men were prohibited from having earrings, interns wore short, white coats, medicine interns were given white pants, and we all wore our department ties to grand rounds on Friday.  Although I loved scrubs and sneakers as a resident, I now run on the conservative side when it comes to dress code and I admit, I’m somewhat a product of my professional upbringing.  Many hospitals still prohibit the display of tattoos in the clinical area.  The culture around tattoos has changed dramatically over the last 20 years and I suspect will change even more over the next 20 years. I know plenty of docs who have tattoos, though most have them in areas where they’re covered by a scrub top or a white coat.  While I don’t think I’d hire a doc with face tattoos at this point, I wouldn’t rule out face tattoos becoming mainstream in the future.  With that said, a recent study suggests that whether doctors have visible tattoos or piercings does not significantly impact the perception the patient has of them.[2] Depending on the environment and patient population, it’s likely that some patients may relate better to physicians who have visible tattoos.

Conclusions

A dress code establishes guidelines and expectations, and that may be essential in some departments where there’s a lot of dress variability and/or some unprofessional dressers who wouldn’t otherwise respond to a private office conversation. Patients have expectations about how physicians should dress and being quickly trusted by the patient can help establish patient-physician rapport, which can positively impact patient satisfaction.  But don’t think this will be a walk in the park discussion with your docs.  This may be a very contentious issue. Considerations include your patient population, your actual work environment (how likely are you do get bloody or do an invasive procedure), and your hospital culture. While white coats continue to be a mainstay of the physician uniform, in our work environment, scrubs may also be completely appropriate. The ultimate goal is to have a relatively standardized and professional appearance for each member of the staff.

References

  1. https://bmjopen.bmj.com/content/bmjopen/8/5/e021239.full.pdf
  2. https://emj.bmj.com/content/35/9/538

 

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

2 Comments

  1. shadi sarmast samimi on

    I am anesthetist and I have been working in intensive care for several years. At the beginning of my career, I thought that it was not so important that it was not so important, but rather the relationship that is created with the relatives of the patients. I have to tell you that over time I changed my mind, as much as you are prepared or try to create empathy with your family members, the appearance is very important and comes proma of every opinion

  2. Jerry W. Jones, MD on

    I’m in favor of scrubs or at least scrub tops with neat pants. White starched coats are beautiful, look very professional and establish your authority as the man or woman in charge. However, one small smudge and you become “that doctor in the filthy lab coat.” Scrubs are easily changed if they get dirty.

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