Imagine you were opening your very own medical practice from scratch. It would be your chance to build a practice just the way you had always wanted. You would have a lot of decisions to make about things like clinic layout, staffing, electronic health record selection, etc.
One seemingly trivial item you would ultimately arrive at is this: what do you and your colleagues wear to work? We’ve had to answer a number of questions like that since starting our practice, Oak Street Health, in 2012. Yet the implications of this particular question were more far-reaching than we had first expected.
At first glance, the topic of attire seems, well, superficial — nothing a serious medical professional should consider. But today we practice in an environment with a growing focus on value-based care. What if you were to find out that a physician’s attire is measurably important to metrics of patient satisfaction or even to clinical outcomes? The question of attire now becomes more interesting.
I don’t mean to suggest that medical attire is a major driver of public health or the health care economy. As one study of physician attire put it, “we should not oversell the importance of attire. While professional appearance might contribute to first impressions, professional behavior is likely to be far more important to patients and families.”
Yet attire does matter. Our field of medicine is wonderfully more diverse than in years past, and that means simple guidance on neckties and wristwatches is anachronistic at best. What clinicians wear to work is a daily choice that reflects our perspective on whether to prioritize patients’ preferences above our own. That’s a topic worth exploring.
With regard to patient satisfaction, the evidence suggests that patients do care about physician attire. Whether you read literature for internal medicine, dermatology, or family medicine, patients appear to have a consistent preference for “professional” attire — i.e., roughly business casual, with or without a tie — with a white coat. A nicely done meta-analysis from 2014 summarizes this research.
That leaves the issue of clinical outcomes, and here we’re stuck with lots of hypotheses and few randomized controlled trials. Since the days of Semmelweis it’s been recognized that physician hygiene has implications for transmission of infectious diseases. Scrubs were created precisely for prevention of pathogen transmission in the operating theater, yet today they’re worn as much on the subway as in the operating room. The Joint Commission lacks specific evidence-based guidance on whether scrubs must be laundered daily, making them more of a fashion choice than much else. Additionally, neckties and shirt sleeves may act as reservoirs for potentially pathologic agents. In fact, based on this evidence, the United Kingdom’s National Health Service has decreed a controversial “bare below the elbows” policy for hospital-based providers. In other words, while the evidence is less than robust, hypotheses around transmission of infectious disease have led clinicians to wear scrubs and short sleeves, lose the neckties and wristwatches, and wash our white coats as often as we can.
So what did we do at Oak Street Health as we started our practice? We were compelled by the data that patients prefer professional attire and white coats. We were also impressed by the possibility of reducing infectious disease in our population of older adults. Lastly, we considered something else entirely: the cost for our non-physician colleagues to self-fund a wardrobe for the clinic. We ultimately landed on practice-issued scrubs for the entire care team, with personalized embroidered white coats for our licensed providers. This ensures a professional, business casual appearance that may also reduce infection transmission. That the scrubs are provided by our practice is a perk for our teams.
In the end, we took an approach shared by many hospitals and outpatient practices around the world. That’s an encouraging finding, because it suggests that most organizations are operating in accordance with the best evidence. It means we’re in good company at Oak Street, and armed with these data we have a far simpler decision as we get dressed each day.