Wearing Professionalism Thin.

I remember well the first few days of medical school. As a mob we hubbub-ed into the auditorium of the UBC Life Sciences Center to be greeted by the faculty. We were anxious. We were excited. Our antiperspirant was breaking down.

Our first week largely featured people telling us how great we were for getting where we were. You did it, they said. You got in. But once our egos were sufficiently massaged, the tire pumping was tempered with realness – medicine is a profession, and as such demands professionalism. Professionalism, said one of our deans dressed in a tailored three-piece suit with gleaming Italian loafers, was about perceptions. It’s about how people view you. You’re in medicine now, so people are watching. They’re listening. And they’re judging. It was time, he said, to consider deleting our social media accounts lest the embarrassing pictures of our botched keg-stands and scandalous nightclub attire surface for all the world to see. If it isn’t ”becoming of a doctor”, it shouldn’t be out there. If you dare to keep your social, for God’s sake don’t post anything too polarizing. Keep your libertarianism and chem-trail conspiracies to yourself. Of course, dress well, and watch what you say on the bus. Remember, you’re in medicine now.

Professionalism is important, but for many of us the professionalism week was affronting. It felt like being read a riot act, suddenly saddled with a new inviolable code of conduct. To the more stereotypically “millennial” among us with our feelings and sensitivities and general whinginess, it felt dehumanizing. Days ago we’d lived vocally, passionately, and authentically, even if some of our viewpoints and ways of being were challenging to those around us. Today, we were told to button down and tow the line.

Professionalism in medicine too has been increasingly in the media, with a focus on physician attire. Several large studies have recently been conducted on patient preferences regarding their MD’s garb, and the results, we hear, are in. Patients, when surveyed, report preferring their doctor to dress formally – for men, this means donning a white coat and tie. For women, a nice blouse (as is typical in medical literature, no other options were provided for those who may not fit the gender binary).

In the most recent study of roughly 4000 hospitalized patients across several areas of the US, pictures of doctors in white coats and professional attire (or scrubs, if they were surgeons or ER physicians) were rated as more knowledgeable, trustworthy, caring, and approachable than those in casual attire (jeans and a tucked in t-shirt). The authors conclude “patients appear to care about attire and may expect to see their doctor in certain ways”, and suggest hospitals, clinics, emergency departments and ambulatory surgical centres use their results to develop dress codes for physicians (1). The study’s authors have gone on to publish a number of opinion pieces in news outlets and popular websites, advocating for more evidence-based guidelines implementing formal attire in the care setting.

But should we really be demanding docs implement formal attire?

Despite the publicity this study garnered, it’s findings and the commentary generated from it (like the professionalism riot act we were read in our first week of classes) miss the point. They attempt to take a complex, context-dependent, fundamentally qualitative set of circumstances and boil them down into Likert-scale responses and rule-based platitudes. They fail to appreciate the nuanced, multifaceted interactions between humans (in this case, doctors and their patients), and the impressions these interactions leave behind. While no one is arguing against the importance of appropriate attire, the role played by attire (assuming the attire is not offensive) is being overstated here. When it comes to patient satisfaction, clothes are almost certainly secondary to the physician’s ability to listen, express empathy, and communicate their expertise in a respectful, caring fashion. Appearance is flimsy - caring and competent conduct are not. These are the real professionalism. As Dr. Mike Edmond points out, no patient ever chose a physician based on the shininess of their tie (2).

There are points to be made about the arbitrary, culturally-specific, subjective nature of what exactly constitutes "professional attire". There are points to be made about the effects that highly formal attire has on “othering” their patients and creating distance between them on the social hierarchy. There are points to be made about the diversity and changing viewpoints around formality, with many feeling that overly formal attire provides a competence "smokescreen". However, what troubles me more is that studies like this fail to see patients as more than their off-the-cuff perceptions, and fail to see healthcare providers as individuals with dimensions beyond their garb. They fail to grapple meaningfully with the ultimate goals of healthcare interactions – to form a connection with between two humans that facilitates care and healing.

To focus on formal attire as a mainstay of professionalism misses the forest for the trees. In the context of immense job dissatisfaction among MDs, a burnout epidemic, and the growing emphasis on partnering authentically with patients to provide relational, patient-centered care, empowering healthcare professionals to embrace a degree of comfort and authenticity in the workplace seems fitting. While no one is advocating the ripped-jeans and t-shirt look, we ought to ask ourselves whether a few percentage-point hit to a patient’s initial impression of our trustworthiness because we’ve tossed the tie truly matters if it allows us to represent ourselves with autonomy, comfort, and authenticity that we can bring into higher-quality relationships with patients.

References:

(1) Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open 2018;8:e021239. doi: 10.1136/bmjopen-2017-021239

(2) https://haicontroversies.blogspot.com/2018/05/how-i-chose-my-doctor_31.html