Early in the COVID-19 pandemic, Trisha Pasricha, MD, a gastroenterologist and research fellow at Massachusetts General Hospital in Boston, was talking to a patient who had been hospitalized for a peptic ulcer.
Like other physicians in her institution, Pasricha was wearing scrubs instead of a white coat, out of concern that the white coat might be more prone to accumulating or transmitting COVID-19 pathogens. Her badge identified her as a physician, and she introduced herself clearly as “Dr Pasricha.”
The patient “required an emergent procedure, which I discussed with him,” Pasricha told Medscape. “I went over what the procedure entailed, the risks and benefits, and the need for informed consent. The patient nodded and seemed to understand, but at the end of the discussion he said, ‘That all sounds fine, but I need to speak to the doctor first.’ “
Pasricha was taken aback. She wondered, “Who did he think I was the whole time that I was reviewing medical concerns, explaining medical concepts, and describing a procedure in a way that a physician would describe it?”
She realized the reason he didn’t correctly identify her was that, clad only in scrubs, she was less easily recognizable as a physician. And while this type of misidentification happened to physicians of both genders wearing scrubs and no white coat, it was more common for female than for male physicians to be misidentified as technicians, nurses, physician assistants, or other healthcare professionals, according to Pasricha.
Pasricha says she has been the recipient of this “implicit bias” not only from patients but also from members of the healthcare team, and says that other female colleagues have told her that they’ve had similar experiences, especially when they’re not wearing a white coat.
Changing Times, Changing Trends
When COVID-19 began to spread, “there was an initial concern that COVID-19 was passed through surfaces, and concerns about whether white coats could carry viral particles,” according to Jordan Steinberg, MD, PhD, surgical director of the craniofacial program at Nicklaus Children’s Pediatric Specialists/Nicklaus Children’s Health System, Miami, Florida. “Hospitals didn’t want to launder the white coats as frequently as scrubs, due to cost concerns. There was also a concern raised that a necktie might dangle in patients’ faces, coming in closer contact with pathogens, so more physicians were wearing scrubs.”
Yet even before the pandemic, physician attire in hospital and outpatient settings had started to change. Steinberg, who is also a clinical associate professor at Florida International University Wertheim School of Medicine, told Medscape that in his previous appointment at Johns Hopkins University School of Medicine, he and his colleagues “had noticed in our institution, as well as other facilities, an increasing trend that moved from white coats worn over professional attire toward more casual dress among medical staff — increased wearing of casual fleece or softshell jackets with the institutional logo.”
This was especially true with trainees and the “younger generation,” who were preferring “what I would almost call ‘warmup clothes,’ gym clothes, and less shirt-tie-white-coat attire for men or white-coats-and-business attire for women.” Steinberg thinks that some physicians prefer the fleece with the institutional logo “because it’s like wearing your favorite sports team jersey. It gives a sense of belonging.”
Todd Shaffer, MD, MBA, a family physician at University Physicians Associates, Truman Medical Centers and the Lakewood Medical Pavilion, Kansas City, Missouri, has been in at his institution for 30 years and has seen a similar trend. “At one point, things were very formal,” he told Medscape. But attire was already becoming less formal before the pandemic, and new changes took place during the pandemic, as physicians began wearing scrubs instead of white coats because of fears of viral contamination.
Now, there is less concern about potential viral contamination with the white coat. Yet many physicians continue to wear scrubs — especially those who interact with patients with COVID — and it has become more acceptable to do so, or to wear PPE over ordinary clothing, but it is less common in routine clinical practice, said Shaffer, a member of the board of directors of the American Academy of Family Physicians (AAFP).
“The world has changed since COVID. People feel more comfortable dressing more casually during professional Zoom calls, when they have the convenience of working from home,” says Shaffer, who is also a professor of family medicine at University of Missouri-Kansas City School of Medicine.
Shaffer himself hasn’t worn a white coat for years. “I’m more likely to wear medium casual pants. I’ve bought some nicer shirts, so I still look professional and upbeat. I don’t always tuck in my shirt, and I don’t dress as formally.” He wears PPE and a mask and/or face shield when treating patients with COVID-19. And he wears a white coat “when someone wants a photograph taken with the doctors — with the stethoscope draped around my neck.”
Traditional Symbol of Medicine
Because of the changing mores, Steinberg and his colleagues at Johns Hopkins wondered if there might still be a role for professional attire and white coats and what patients prefer. To investigate the question, they surveyed 487 US adults between in the spring of 2020.
Respondents were asked where and how frequently they see healthcare professionals wearing white coats, scrubs, and fleece or softshell jackets. They were also shown photographs depicting models wearing various types of attire commonly seen in healthcare settings and were asked to rank the “healthcare provider’s” level of experience, professionalism, and friendliness.
The majority of participants said they had seen healthcare practitioners in white coats “most of the time,” in scrubs “sometimes,” and in fleece or softshell jackets “rarely.” Models in white coats were regarded by respondents as more experienced and professional, although those in softshell jackets were perceived as friendlier.
There were age as well as regional differences in the responses, Steinberg said. Older respondents were significantly more likely than their younger counterparts to perceive a model wearing a white coat over business attire as being more experienced, and — in all regions of the US except the West coast — respondents gave lower professionalism scores to providers wearing fleece jackets with scrubs underneath.
Respondents tended to prefer surgeons wearing a white coat with scrubs underneath, while a white coat over business attire was the preferred dress code for family physicians and dermatologists.
“People tended to respond as if there was a more professional element in the white coat. The age-old symbol of the white coat still marked something important,” Steinberg said. “Our data suggest that the white coat isn’t ready to die just yet. People still see an air of authority and a traditional symbol of medicine. Nevertheless, I do think it will become less common than it used to be, especially in certain regions of the country.”
Organic, Subtle Changes
Christopher Petrilli, MD, assistant professor at NYU Grossman School of Medicine in New York City, conducted research in 2018 regarding physician attire by surveying over 4000 patients in 10 US academic hospitals. His team found that most patients continued to prefer physicians to wear formal attire under a white coat, especially older respondents.
Petrilli and colleagues have been studying the issue of physician attire since 2015. “The big issue when we did our initial study — which might not be accurate anymore — is that few hospitals actually had a uniform dress code,” said Petrilli, the medical director of Clinical Documentation Improvement and the clinical lead of Value-Based Medicine at NYU Langone Hospitals. “When we looked at ‘honor roll hospitals’ during our study, we cold-called these hospitals and also looked online for their dress code policies. Except for the Mayo Clinic, hospitals that had dress code policies were more generic.”
For example, the American Medical Association (AMA) guidance merely states that attire should be “clean, unsoiled, and appropriate to the setting of care” and recommends weighing research findings regarding textile transmission of healthcare-associated infections when individual institutions determine their dress code policies. The AMA’s last policy discussion took place in 2015 and its guidance has not changed since the pandemic.
Regardless of what institutions and patients prefer, some research suggests that many physicians would prefer to stay with wearing scrubs rather than reverting to the white coat. One study of 151 hospitalists, conducted in Ireland, found that three quarters wanted scrubs to remain standard attire, despite the fact that close to half had experienced changes in patients’ perception in the absence of their white coat and “professional attire.”
Jennifer Workman, MD, assistant professor of pediatrics, Division of Pediatric Critical Care, University of Utah School of Medicine in Salt Lake City, told Medscape that, as the pandemic has “waxed and waned, some trends have reverted to what they were prepandemic, but other physicians have stayed with wearing scrubs.”
Much depends on practice setting, says Workman, who is also the medical director of pediatric sepsis at Intermountain Care. In pediatrics, for example, many physicians prefer not to wear white coats when they are interacting with young children or adolescents.
Like Shaffer, Workman has seen changes in physicians’ attire during video meetings, where they often dress more casually, perhaps wearing sweatshirts. And in the hospital, more are continuing to wear scrubs. “But I don’t see it as people trying to consciously experiment or push boundaries,” she says. “I see it as a more organic, subtle shift.”
Petrilli thinks that, at this juncture, it’s “pretty heterogeneous as to who is going to return to formal attire and a white coat and who won’t.” Further research needs to be done into currently evolving trends. “We need a more thorough survey looking at changes. We need to ask [physician respondents], ‘What is your current attire, and how has it changed?’ “
Navigating the Gender Divide
In their study, Steinberg and colleagues found that respondents perceived a male model wearing business attire underneath any type of outerwear (white coat or fleece) to be significantly more professional than a female model wearing the same attire. Respondents also perceived males wearing scrubs to be more professional than females wearing scrubs.
Male models in white coats over business attire were also more likely to be identified as physicians, compared with female models in the same attire. Females were also more likely to be misidentified as nonphysician healthcare professionals.
Shikha Jain, MD, assistant professor of medicine at the University of Illinois Cancer Center in Chicago, told Medscape that Steinberg’s study confirmed experiences that she and other female physicians have had. Wearing a white coat makes it more likely that a patient will identify you as a physician, but women are less likely to be identified as physicians, regardless of what they wear.
“I think that individuals of color and especially people with intersectional identities — such as women of color — are even more frequently targeted and stereotyped. Numerous studies have shown that a person of color is less likely to be seen as an authority figure, and studies have shown that physicians of color are less likely to be identified as ‘physicians,’ compared to a Caucasian individual,” she said.
Does that mean that female physicians should revert back to prepandemic white coats rather than scrubs or more casual attire? Not necessarily, according to Jain.
“The typical dress code guidance is that physicians should dress ‘professionally,’ but what that means is a question that needs to be addressed,” Jain said. “Medicine has evolved from the days of house calls, in which one’s patient population is a very small, intimate group of people in the physician’s community. Yet now, we’ve given rebirth to the ‘house call’ when we do telemedicine with a patient in his or her home. And in the old days, doctors often had offices their homes and now, with telemedicine, patients often see the interior of their physician’s home.” As the delivery of medicine evolves, concepts of “professionalism” — what is defined as “casual” and what is defined as “formal” — is also evolving.
The more important issue, according to Jain, is to “continue the conversation” about the discrepancies between how men and women are treated in medicine. Attire is one arena in which this issue plays out, and it’s a “bigger picture” that goes beyond the white coat.
Jain has been “told by patients that a particular outfit doesn’t make me look like a doctor or that scrubs make me look younger. I don’t think my male colleagues have been subjected to these types of remarks, but my female colleagues have heard them as well.”
Even fellow healthcare providers have commented on Jain’s clothing. She was presenting at a major medical conference via video and was wearing a similar outfit to the one she wore for her headshot. “Thirty seconds before beginning my talk, one of the male physicians said, ‘Are you wearing the same outfit you wore for your headshot?’ I can’t imagine a man commenting that another man was wearing the same jacket or tie that he wore in the photograph. I found it odd that this was something that someone felt the need to comment on right before I was about to address a large group of people in a professional capacity.”
Addressing these systemic issues “needs to be done and amplified not only by women but also by men in medicine,” said Jain, founder and director of Women in Medicine, an organization consisting of women physicians whose goal is to “find and implement solutions to gender inequity.”
Jain said the organization offers an Inclusive Leadership Development Lab — a course specifically for men in healthcare leadership positions to learn how to be more equitable, inclusive leaders.
A Personal Decision
Pasricha hopes she “handled the patient’s misidentification graciously.” She explained to him that she would be the physician conducting the procedure. The patient was initially “a little embarrassed” that he had misidentified her, but she put him at ease and “we moved forward quickly.”
At this point, although some of her colleagues have continued to wear scrubs or have returned to wearing fleeces with hospital logos, Pasricha prefers to wear a white coat in both inpatient and outpatient settings because it reduces the likelihood of misidentification.
And white coats can be more convenient — for example, Jain likes the fact that the white coat has pockets where she can put her stethoscope and other items, while some of her professional clothes don’t always have pockets.
Jain notes that there are some institutions where everyone seems to wear white coats, not only the physician — “from the chaplain to the phlebotomist to the social worker.” In those settings, the white coat no longer distinguishes physicians from nonphysicians, and so wearing a white coat may not confer additional credibility as a physician.
Nevertheless, “if you want to wear a white coat, if you feel it gives you that added level of authority, if you feel it tells people more clearly that you’re a physician, by all means go ahead and do so,” she said. “There’s no ‘one-size-fits-all’ strategy or solution. What’s more important than your clothing is your professionalism.”