The White Coat Halo

I am so excited to be back in the department.  The front end of my intern year has been off-service heavy, and, while I appreciate the learning opportunities I have had, it is so validating to be working in the field I have chosen. As I scurry between patient encounters and chat with my co-residents, I have begun to notice something peculiar about the sartorial choices of some of the younger attendings. Whereas rejection of our short white coats seemed to be a point of bonding on the residency interview trail, I have noticed several of the younger, female attendings donning their long white coats while on shift. In a field of physicians who pride themselves on being on the frontlines of the house of medicine, down in the trenches, the grittiest of the gritty, why are some of us choosing a difficult to clean, prominent and somewhat paternalistic symbol to wear for our day to day work?

It may seem that the white coat has always accompanied the physician on her rounds, but the pure white laboratory coat is a relatively recent addition to our uniform. The father of clinical medicine Hippocrates only specified that doctors "must be clean in person, well dressed, and anointed with sweet-smelling unguents" (Rehman et al., 2005). Prior to the 19th century, formal black clothing was the preferred attire for a physician in order to confer gravity and importance to the provider's visits. This dress code is exemplified by the famous Eakins painting "The Gross Clinic," where Dr. Gross is surrounded by a throng of somberly dressed colleagues. Shortly after completing his painting of physicians decked out in traditional black, Eakins subsequently captured the advent of sanitation and cleanliness that would come to characterize modern medicine in his portrayal of Dr. Agnew's operating theater; white sheets cover the patient and nurses have donned white caps (Hochberg, 2007). Adoption of the white coat coincided with a revolution in the medical profession brought about by basic science and standardization of medical education in the aftermath of the Flexner report. The white coat conferred a veneer of scientific validity, cleanliness and a higher purpose to a profession which prior to the industrial revolution had been rank with quackery and dismal outcomes (Kazory, 2008). The white coat has been a prominent feature of the physician's costume for over 100 years (Brase & Richmond, 2004), and is likely over-represented in the modern conception of what a doctor wears because its introduction coincided with the scientific revolution which birthed modern medicine.

While germ theory and hand-washing are still engrained in my practice, the white coat's comfortable position on the shoulders of my peers seems in peril. Even as early as the 1980s, physicians were already choosing to ditch the white coat (Colt & Solot, 1989). In 1991 70% of physicians and medical students wore their white coats most of the time, but by 2004 only 13% of doctors reported regularly wearing their long coats. Paradoxically, one of the main reasons physicians cite for discarding the white coat is infection risk: it only takes a week for white coats to become fully saturated with frightening microbes, including MRSA. Some guidelines even stipulate removing the coat before encountering a patient, as well as specifying a minimum number of coats to provide (two) for laundering purposes  (Bearman et al., 2014). Some astute authors have pointed out the colonization does not necessarily imply transmission (Kazory, 2008), and there is an absence to date of any study specifically implicating white coat-wearing physicians as discrete vectors for hospital-acquired infection (Petrilli et al., 2018). However, if the potential for infectious risk is not enough of a deterrent to the would-be-frocked physician, then perhaps concerns about the effect the coat might have on the doctor-patient relationship could stay our collective hands from pulling our coats off their hooks. There is a general impression that overly formal dress and signifiers of authority lead patients to perceive their doctors as unfriendly, unapproachable or less understanding. For women, in particular, there is some evidence that male patients regard women in white coats as less friendly, less attractive and less trustworthy (Brase & Richmond, 2004). The enlightened, patient-centered doctor eschews the white coat to make herself more approachable to patients, or at least that is the justification some of us use for leaving the coat on the back of the chair.

Figuring out just what patients actually want is less straightforward. A recent meta-analysis of 30 studies regarding patient preferences for physician attire reported: "formal attire was almost always preferred followed closely by white coats either with or without formal attire,” (Petrilli et al., 2015). Another survey of college students showed that trust and willingness to confide in a physician loaded onto authority in a factor analysis of physician dress and potential patient preferences (Brase & Richmond, 2004). A randomized, cross-sectional survey of outpatients and visitors in a VA waiting room showed an overwhelming preference for professional attire, including a white coat, in 76.3% of respondents when shown pictures of hypothetical physicians in various levels of formal dress. Wearing a white coat was associated with self-reported trust and confidence in the provider, as well as willingness to disclose private details about sexual history, social and psychological issues. Professional dress was particularly salient for female physicians in this population, with female respondents driving the finding by ranking a female physician's appearance as significantly more important than that of a male's (Rehman et al., 2005). A follow-up study to the previously discussed 2015 meta-analysis distributed surveys to 10 academic centers across the US in order to ascertain patients’ preferred physician attire in different clinical settings. The authors showed that formal attire with a white coat was generally associated with higher ratings of knowledge, trustworthiness, caring, and approachability (Petrilli et al., 2018). It appears, then, that appearing authoritative and professional with a white coat sets the stage for a good patient-doctor relationship. Yet the initial meta-analysis also reported that only 4 out of 10 studies in the US found any influence of physician attire on patient satisfaction (Petrilli et al., 2015). One study cited in the meta-analysis noted that patients often failed to recall their physician's attire when surveyed after the visit (Boon et al. 1994, as cited in Petrilli et al., 2015). Another, earlier review of the white coat versus patient satisfaction literature cites a study wherein roughly 30% of patients could not accurately recall whether their provider wore a necktie during their encounter, but that the recollection of a necktie improved their satisfaction of the visit regardless of what their physician truly wore (Pronchik et al., 1998, as cited in Bianchi, 2008). Clearly there is some confusion about what patients expect and what specifically influences their experience of the patient-doctor relationship.

Perhaps some of the heterogeneity in the data is due to the variety of domains with differing expectations of dress where a patient might encounter a physician. Specifically, do patients in acute care settings such as emergency departments have more consistent opinions about what their doctors should wear? An early study of attitudes towards physician attire in the emergency department showed that 49% of patients queried felt emergency medicine physicians should wear white coats when seeing patients, which is significantly less than the previously reported patient percentages favoring more formal dress. Surprisingly, there was also no difference in patient preference between female or male physicians with respect to wearing white coats (Colt & Solot, 1989). In a later randomized controlled trial, physicians dressed formally in a white coat for one week and then informally in scrubs with no white coat for another week. There were no differences between patients’ evaluations of appearance, satisfaction, or professionalism, and again physician gender did not seem to influence the patients' responses (Li & Haber, 2005). Petrilli's massive, multi-site survey was specifically designed to assess attitudes toward physician dress in a variety of care settings, and, in opposition to their overall conclusion that patients prefer physicians in formal clothes with a white coat on top, patients preferred doctors in the ER and OR to be wearing scrubs (2018). 

So, although patients, in general, prefer doctors in formal dress and white coats, there is good evidence that patients can be reasonable people and that can accept scrubs as appropriate attire for the emergency department. This brings me back to my original question, then; why the seeming preference for white coats among female providers? A study in 2006 where patients were asked whether they had seen a doctor shortly after their first encounter with a physician might hold the answer: where patients recognized 93.3% of male physicians as physicians, only 79.5% of female physicians were identified as such (Prince, Pipas, & Brown, 2006). This was the only study I could find where patients were not directly told that the woman they were looking at was their physician. Rehman et al. accounted for the emphasis their sample at the VA placed on female appearance by arguing "respondents may feel that women physicians need to make an extra effort to appear professional, so that they are not confused with nurses, dietitians, social workers, etc..." (2005). Facilitating identification by colleagues and patients is the most common reason physicians of both genders cite for wearing a white coat (Kazory, 2008). Failure to be recognized by consultants in a busy ED could also be motivating my attendings, especially since physicians themselves tend to prefer other physicians in white coats, perhaps more than our patients do (Bianchi, 2008).

Personally, I have yet to make it through an entire shift without being mistaken for a different healthcare professional. I was required to wear my white coat while on some off-service rotations, and the supposed emblem of my profession provided me no protection from being called "nurse," even by other attending physicians. None of the studies I read addressed the dilution of the white coat's meaning as other professionals don the long laboratory coat, presumably to access some of the implicit authority the article of clothing confers. It would be interesting to study whether wearing a white coat in the emergency department is more effective in signaling my role to patients and fellow providers. One could ask whether my patients expect me to be in the coat since I am a doctor, or if they would mistrust me for actively assuming a role not conventionally occupied by women. Many of the studies discussed above compared formal dress with a white coat to just scrubs; would the "white coat halo" still hold if placed over scrubs elsewhere in the hospital? Will zip-up fleece jackets eventually supplant white coats with their superior warmth and better fit? While pondering these potential research projects, I will likely be wearing my white coat because I need the extra pockets for my snacks.

Works Cited

• Bearman, G., Bryant, K., Leekha, S., Mayer, J., Munoz-Price, L. S., Murthy, R., . . . White, J. (2014). Healthcare Personnel Attire in Non-Operating-Room Settings. Infection Control & Hospital Epidemiology,35(02), 107-121. doi:10.1086/675066
• Bianchi, M. T. (2008). Desiderata or Dogma: What the Evidence Reveals About Physician Attire. Journal of General Internal Medicine,23(5), 641-643. doi:10.1007/s11606-008-0546-8
• Brase, G. L., & Richmond, J. (2004). The White–Coat Effect: Physician Attire and Perceived Authority, Friendliness, and Attractiveness. Journal of Applied Social Psychology,34(12), 2469-2481. doi:10.1111/j.1559-1816.2004.tb01987.x
• Colt, H. G., & Solot, J. A. (1989). Attitudes of patients and physicians regarding physician dress and demeanor in the emergency department. Annals of Emergency Medicine,18(2), 145-151. doi:10.1016/s0196-0644(89)80104-0
• Hochberg, M. S. (2007). The Doctors White Coat--an Historical Perspective. Virtual Mentor,9(4), 310-314. doi:10.1001/virtualmentor.2007.9.4.mhst1-0704
• Kazory, A. (2008). Physicians, Their Appearance, and the White Coat. The American Journal of Medicine,121(9), 825-828. doi:10.1016/j.amjmed.2008.05.030
• Li, S. F., & Haber, M. (2005). Patient attitudes toward emergency physician attire. The Journal of Emergency Medicine,29(1), 1-3. doi:10.1016/j.jemermed.2004.12.014
• Petrilli, C. M., Mack, M., Petrilli, J. J., Hickner, A., Saint, S., & Chopra, V. (2015). Understanding the role of physician attire on patient perceptions: A systematic review of the literature-- targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open,5(1). doi:10.1136/bmjopen-2014-006578
• Petrilli, C. M., Saint, S., Jennings, J. J., Caruso, A., Kuhn, L., Snyder, A., & Chopra, V. (2018). Understanding patient preference for physician attire: A cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open,8(5). doi:10.1136/bmjopen-2017-021239
• Prince, L. A., Pipas, L., & Brown, L. H. (2006). Patient perceptions of emergency physicians: The gender gap still exists. The Journal of Emergency Medicine,31(4), 361-364. doi:10.1016/j.jemermed.2006.04.011
• Rehman, S. U., Nietert, P. J., Cope, D. W., & Kilpatrick, A. O. (2005). What to wear today? Effect of doctor’s attire on the trust and confidence of patients. The American Journal of Medicine,118(11), 1279-1286. doi:10.1016/j.amjmed.2005.04.026

Jessica Krueger, MD, PGY-1
Einstein Healthcare Network
AAWEP Junior Resident Representative