Does Wearing a White Coat Improve Patient-Provider Relationships?

Calling all doctors with a passion for fashion: the latest peer-reviewed survey data shows your patient-provider relationships might be stronger when you wear a white coat. The survey showed patients perceive white coats as more professional than casual wear.

The finding, published in JAMA Network Open, comes as healthcare professionals work to establish good interpersonal relationships and rapport with patients, while also gaining the trust and confidence of their patients. Although more casual wear, like fleeces or softshell jackets, in theory could temper the power hierarchy inherent during a medical encounter, the study found that patients want their doctors to look the part.

“Despite its longstanding history, the white coat has come under some scrutiny,” wrote the researchers, who hail out of the Johns Hopkins University School of Medicine.

Some data has shown white coats can spread germs, prompting calls for regular laundering and certain design changes, like exposed wrists and forearms.

“Moreover, some medical specialties find it more practical not to wear the white coat, particularly surgeons who find scrubs to be more pragmatic attire for transitioning between operating rooms, the clinic, and the hospital floor.”

And that is on top of the push for more team-based care in which physicians collaborate with, and sometimes defer to, advanced practice providers. Getting rid of the white coat can stand as a symbolic measure for diving into team-based care and getting rid of interprofessional power hierarchies.

But the data showed that patients aren’t entirely keen on these measures, with most saying doctors in white coats look more professional, experienced, and friendly than doctors who opt for more casual fashion choices.

The researchers presented 487 patients with pictures of male and female models wearing various types of medical attire, including scrubs, business attire, and white coats. Patients rated each photo on a five-point scale, with ratings relating to professionalism, experience, and friendliness.

Overall, the results showed patients preferred doctors wearing white coats, with patients giving them a 4.9 “experienced” rating. This compares to a 3.1 rating for doctors wearing fleeces and a 3.1 rating for doctors wearing softshell jackets. Patients also said doctors wearing white coats were more professional (a 4.9 rating) than those wearing a softshell jacket (3.3 rating).

“Lower experience ratings for casual physician attire may be explained by more limited exposure of the public to these garments owing to their novelty or by the association of these garments with younger wearers often still in medical training,” the researchers wrote. “Therefore, there have been few opportunities for the public to associate casual physician attire with valued physician characteristics.”

There is room for this to change. For example, younger survey respondents were more likely to rate casual attire still as professional, likely because they are more used to this kind of attire on their clinicians.

There was some variation across medical specialties. For example, patients prefer a surgeon wearing scrubs plus a white coat, but they think family physicians and dermatologists wearing business attire plus a white coat look more professional and experienced than when they wear other outfits.

The researchers did acknowledge some of the sanitary reasons for getting rid of the white coat, giving a nod to some previous findings stating that the white coat can carry germs. This is particularly salient during the COVID-19 pandemic.

“However, the formal acknowledgment of the white coat’s role as a fomite may have led to the unintended further supplantation by casual physician attire, which in actuality may not be cleaner than white coats owing to a lack of regulations,” the researchers explained. “As casual garments become more ubiquitous among all health care personnel, further research on sanitization standards will be critical, including garments’ roles as fomites and trends in hospital vs home wear.”

What’s more, the researchers found signals of gender-based implicit bias, with patients rating male model physicians as being more professional than females. And even though respondents overwhelmingly identified images as being of surgeons, regardless of gender, female models were more often mistaken as medical technicians, physician assistants, and nurses than their male peers.

This could stem back to what the researchers called the “lack-of-fit” model. This model dictates that respondents will rate candidates based on what they think a professional physician or surgeon should “look like.”

“In this model, diversity is penalized because the candidate is judged based on stereotype rather than merit,” the researchers said. “The stereotype used by a rater to determine whether a candidate is fit is formed and influenced by personal experiences, culture, and exposure to health care and can therefore be affected by experience and education.”

And taken further, the researchers posited lack of gender diversity in the physician field could be playing a role. Although medicine is seeing increasing diversity, it remains that most doctors are men, and most nurses are women. This ultimately fortifies patients’ preconceived notions and could perpetuate an at-best annoying stereotype.

Proposed solutions like dressing more “professionally” to help women be accurately identified as a physician might ultimately be counterproductive, the researchers furthered. This, in fact, could take away from a female physician’s clinical work, which ultimately is the most important part of her job.

“Addressing gender bias is critical to promoting diversity and improving patient outcomes and should not be a responsibility solely undertaken by women; instead, it should be the responsibility of all health care workers to contribute to lasting change,” the research team wrote.

At the end of the day, a physician’s fashion choice isn’t the end-all, be-all for patient-provider relationships. Again, clinical work is the most important part of a physician’s job.

Regardless of what they are wearing, all clinicians should identify themselves when meeting with a patient. And for physicians who choose to wear more casual attire, using other patient-provider communication strategies to build rapport—personalized communication and provider empathy—will be essential, the researchers recommended.

And meanwhile, potential culture shifts in physician workplace attire could open doors to changing paradigms in gender-based implicit bias.

“The introduction of new physician attire presents a disruptive opportunity to address persistent gender biases in medicine. 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,” the researchers stated.

“This responsibility should not be undertaken only by the individuals that experience the biases, which may result in additional cumulative career disadvantages,” they concluded. “The promotion of equality and diversity begins with recognition, characterization, and evidence-supported interventions and is a community operation.”