White Coat Beats Casuals in Patient Perceptions, With Gender Caveats

A physician who wears a traditional white coat appears more professional and experienced compared with one who is dressed in more-casual attire, according to new survey data. That said, biases to the detriment of women physicians remain blatant regardless of what they wear.

“Physician attire is only a small aspect of the practice of medicine and does not embody the wearer’s qualifications, nor does it necessarily affect their performance, practice, and contributions,” write lead author Helen Xun, MD (Johns Hopkins University School of Medicine, Baltimore, MD), and colleagues. “However, as physician attire evolves, the healthcare community should be attuned to the potential associations attire may have with the primary objective of the profession to provide excellent patient care.”

The paper, published online last week in JAMA Network Open, is the latest to address attire and professionalism in healthcare. Last years’ #MedBikini paper spurred debate about physicians posting photos of themselves in “inappropriate attire” on social media.

But in the clinic, patient perceptions matter, as physician attire is linked with “building rapport with patients, reducing risks of nosocomial pathogen transmission, and communicating physicians’ role in patient care,” the authors write. “Physicians in casual physician attire should be conscious of the different impression they may give to patients compared with physicians in a white coat and mitigate this through other methods of building patient rapport.”

Amalia Cochran, MD (Bozeman, MT), who co-wrote an accompanying editorial with Gilbert R. Upchurch Jr, MD (University of Florida Health, Gainesville), told TCTMD that the survey “provides an important contribution in terms of highlighting the fact that there is a diversity of opinions out there in terms of what constitutes professional attire—that there's not one single right answer to that question—and unfortunately for women physicians, it kind of didn't matter what we showed up in. There was still the ‘wait for the doctor’ question that came into play.”

Does this mean that women should show up to work in whatever they want? Maybe, Cochran said. “Perhaps the [fact] that there really wasn't a clear-cut answer for women really does still highlight a lot of unconscious bias that is still present regarding the role of women as physicians, which is unfortunate but that's just something that takes time. And then I think the other piece of that is that for women, perhaps we really do have a broader bandwidth in terms of what we should wear, because if a white coat isn't necessarily giving us any additional cachet, maybe we should kind of make our own rules.”

‘A Disruptive Opportunity’

Casual attire, defined in this survey as either fleece or softshell jackets often emblazoned with an institution’s insignia, was associated with lower perceptions of both professionalism and experience compared with white coats, according to 487 respondents to the online image survey sent out between May and June 2020.

Attire Comparison

The preferred outfit changed according to specialty, with respondents reacting most positively to a white coat with scrubs for surgeons and a white coat with business attire for family physicians and dermatologists.

Notably, regardless of what women wore in the survey images, respondents rated them as less professional than men (56.2 vs 65.8; P < 0.001). When dressed similarly in white coats with business wear, female and male models were most frequently identified as physicians, although men were thought to be doctors more often than women (71.7% vs 88.3%; P < 0.001). In contrast to the male model, for example, the female model was mistaken by more respondents as a medical technician (8.0% vs 3.3%; P < 0.005), physician assistant (11.5% vs 2.3%; P < 0.001), or nurse (33.1% vs 27.3%; P = 0.050).

“The introduction of new physician attire presents a disruptive opportunity to address persistent gender biases in medicine,” Xun and colleagues write. “With exposure and education, public perception of physicians can be broadened to reflect increasing diversity as the new status quo. This includes clear identification of professional roles during introductions, immediate correction of role misidentifications, and increased visibility (such as more diverse representation at all levels of training; spotlight features; representation on boards, as speakers, and in leadership positions; and presence on social media).”

Tradition, Practicality

Cochran said she has noticed more physicians moving away from the white coat, suggesting that certain regions may be less tied to the tradition or that this attire might not be practical for specific specialties. “I have practiced for the bulk of my career in the West, and specifically in the Mountain West, and I felt like white coats were largely out of favor amongst my colleagues. Not just my surgeon colleagues, not just my critical care colleagues, but across the board.”

There is a diversity of opinions out there in terms of what constitutes professional attire . . . and unfortunately for women physicians, it kind of didn't matter what we showed up in. Amalia Cochran

Moving away from the white coat is a good thing, she continued. “It does help to smooth the power differential between the physician and patients and families to not have it. . . . There are times, of course, that you as a physician would perhaps want to be recognized for your expertise and your knowledge and your experience. I think that's understandable. But hopefully that can be done through really thoughtful conversations with patients and family members, and perhaps it doesn't require that marker that a white coat has traditionally been thought to provide for us.”

There does still remain the question of whether white coats may enable infection to spread more easily in the hospital setting, Cochran acknowledged. “The data around that is equivocal, it's imperfect. But I think at least acknowledging that there is that possibility is another reason that people in critical care environments have stepped back from wearing white coats,” she said.

Ultimately, the evolution of professionalism in medicine is ongoing and attire is only part of that.

“One of the challenges that I really see us having is that a lot of us want to think about professionalism as something that's positive, and that's creating an inclusive culture and a place of civility and kindness,” Cochran said. “But I also know there are times, particularly in education, that professionalism is being weaponized, and if someone acts in a way or dresses in a way that you don't think is quite right, . . . boy, it's a fine line sometimes. I think we're all definitely trying to navigate that professionalism space in a way that it's supportive of everybody and really acknowledging that times are changing still, and this is one piece of that. I think #MedBikini is one piece of that. I think any time these professionalism questions come up, they get really complicated, really quickly.”