Patient perception of physician appearance: a concern for all physicians.

In an age of consumerist medicine and patient mistrust of physicians due to massive, and generally negative, media coverage of physicians, the patient's perception of their physician has become an important area of concern. The appearance of a physician may influence anything from the patient's opinions of physician competence to compliance with prescribed treatments. In current American society, casual dress has become commonplace, which has carried over into physicians' offices. Now, one is more likely to see the medical staff in a primary care practice wearing scrubs than wearing traditional work attire (slacks, shirt, and tie for men; skirt and blouse for women).

Although a significant amount of research has been conducted in the area of physician appearance, little research has been conducted within the past 5 years to assess how patients feel about the move toward less traditional attire. There are several important points to address with such research. First, it is not clearly understood whether the less traditional attire, which many physicians favor, impacts (negatively or positively) patients' perceptions of physician competence. Second, it is not known whether patients' impressions are limited to first-time encounters, such as initial consultations, or whether this phenomenon extends to all patient contacts. Finally, little is known about patients' abilities to distinguish between medical personnel in the age of ubiquitous scrubs. Overall, however, the question of what type of appearance makes patients comfortable is relevant to all physicians, both those in training and those already practicing.

The article by Keenum et al (1) attempts to address the first of these points in this month's issue of the Southern Medical Journal. In their study, Keenum et al (1) queried family medicine patients on physician appearance traits at two outpatient family medicine clinics: one suburban private practice office and one clinic affiliated with a large teaching hospital. This study was novel in that it is one of the few studies on this topic that have been conducted in the United States, and it was the first that could be found that was conducted in the southeastern region of the United States. The study questionnaire was based on those used in other studies and used a Likert-type scale for patient response. The questionnaire was tested for content validity by a panel of "experts" and modified in accordance with their recommendations. Test-retest reliability was determined using 1-week intervals in a group not described in the study.

Not surprisingly, patient opinions in this study did not differ substantially from those in previous studies. The majority of patients found traditional physician attributes, such as white coats and nametags, desirable. Conversely, nontraditional characteristics, such as clogs and sandals, were found to be undesirable to patients. The findings from this study correlate well with findings from other similar studies conducted in adult outpatient settings. (2-9) Only one study could be found that reported that patients did not prefer traditional dress, such as a white coat, and this study was conducted 13 years ago in a different culture. (10)

The current study did not report novel findings; however, it does reinforce the idea that patients prefer professional dress to casual attire. In addition, the props commonly associated with physicians (stethoscope, name tag, and white coat) elicit positive responses from patients. Several possible limitations from this study temper our ability to generalize results to other patient populations. The sample in the study by Keenum et al (1) was disproportionately female (72.6%); however, this may be appropriate, given that female patients use health care resources at a significantly higher rate than male patients. (11) The study also did not include patients under the age of 20 years, which is problematic because a significant proportion of family medicine patients are in this age range. Finally, asking patients to qualify characteristics as desirable or undesirable requires a value judgment, which may bias or lead patients to arrive at a predetermined conclusion. An alternative approach would be to rank characteristics.

Although the current study and the ones mentioned previously address satisfactorily the issue of patient attitudes toward physician dress, none of them address either the second or the third points listed in the first paragraph. No one knows whether patient attitudes are formed only as a first impression at the initial meeting or whether appearance continues to be important at subsequent meetings. In addition, there have been anecdotal reports of patients being frustrated and confused by the number of medical office staff they encounter during an average clinic visit. In many clinics, it can be difficult to distinguish between front office staff, nurses, medical technicians, and physicians. Keenum and colleagues did not address this area of concern in the current study.

Although today there are many important concerns that demand the attention of the primary care physician, the concept of patient perceptions of physicians remains a "hot topic." Patients' attitudes toward their physicians can influence many aspects of their health care, from the communication process to compliance with prescribed regimens. It is important for physicians to be aware of the trend toward patient preference for traditional attire; however, the physician must remain sensitive to special situations when deviations from this standard may be appropriate.

Accepted September 29, 2003.

References

(1.) Keenum AJ, Wallace LS, Stevens ARB. Patients' attitudes regarding physical characteristics of family practice physicians. South Med J 2003; 96:1190-1194.

(2.) Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract 1998;15:391-397.

(3.) Friis R, Tilles J. Patients' preferences for resident physician dress style. Fam Pract Res J 1988;8:24-31.

(4.) Dunn JJ, Lee TH, Percelay JM, et al. Patient and house officer attitudes on physician attire and etiquette. JAMA 1987;257:65-68.

(5.) Gooden BR, Smith MJ, Tattersall SJ, et al. Hospitalised patients' views on doctors and white coats. Med J Aust 2001;175:219-222.

(6.) McKinstry B, Wang JX. Putting on the style: What patients think of the way their doctor dresses. Br J Gen Pract 1991;41:270, 275-278.

(7.) McNaughton-Filion L, Chen JS, Norton PG. The physician's appearance. Fam Med 1991;23:208-211.

(8.) Dover S. Glasgow patients' attitude to doctors' dress and appearance. Health Bull (Edinb) 1991;49:293-296.

(9.) Gjerdingen DK, Simpson DE, Titus SL. Patients' and physicians' attitudes regarding the physician's professional appearance. Arch Intern Med 1987;147:1209-1212.

(10.) Anvik T. Doctors in a white coat: What do patients think and what do doctors do? Scand J Prim Health Care 1990;8:91-94.

(11.) Woodwell DA. National Ambulatory Medical Care Survey: 1995 summary. Adv Data 1997;286:1-25.

From the Department of Family and Sports Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Reprint requests to Douglas F. Aukerman, MD, Department of Family and Sports Medicine, James H. Quillen College of Medicine, East Tennessee State University, W127 Memorial Center, Box 70707, Johnson City, TN 37614. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association

0038-4348/03/9612-1172