General George Patton and the physician's white coat

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General George Patton was one of the most outstanding military leaders of all time, and many consider Patton to be the greatest of the 20th Century and one of World War II's most outstanding military leaders.

Patton always had an impressive image and was probably a narcissist. He believed in proper dress codes even when he was in battle zones. For example, during his African campaign, he would require everyone to wear leggings to keep out scorpions. He also developed a fining system for soldiers who did not obey the dress code. He emphasized to his troops the importance of proper appearance and hygiene.

Healthcare also has a dress code. I am not implying that a doctor must wear a coat and tie when encountering a patient. (This is the dress code at the Mayo Clinic) However, suppose the doctor has a sloppy dress, poor hygiene, unkempt hair, and dirty nails. In that case, this will not be endearing to patients and will not set an example for the rest of the staff. Each practice and each hospital should have a proper dress code in the employee manual, and the dress code should be enforced and followed by everyone, including doctors.

Let me share a story about the impact of the physician's had on my mother-in-law. I accompanied her to an urgent care center in South Florida. She could not see her PCP and was told to go to the nearest urgent care center. My mother-in-law was greeted by a physician wearing a Polo shirt, jeans, and sandals without socks. He did have a stethoscope around his neck, which was the only symbol to my mother-in-law and me that we were in the company of a physician. He was very friendly and provided her with good care. However, when we left, she said, "Do you think he looked like a doctor?" My answer was, "Of course not." There was no professional aura about this young man, who was very polite and helpful. However, he certainly did not look like a physician. Now, my mother-in-law probably didn't do online surveys, but if she was asked to go online and answer a few questions about her experience with the urgent care center and with the physician, what would you imagine would be her perception of her experience with a doctor who looked like he could have been a checkout clerk at McDonald's, a salesman in a shoe store, or a member of the Geek Squad at Best Buy?

Let me be clear that a white coat doth not a physician make! However, there's no mistaking a man or woman caring for a patient in a white coat that they are a physician. There is no workplace clothing that indicates the wearer's profession as much as a doctor's white coat. (An exception is the priest's white collar.)

Like most of my colleagues, I can clearly remember the excitement and feelings of achievement when I received a short white coat as a medical student. The white coat ceremony was a rite of passage and symbolized the beginning of my medical career. The ceremony signifies the start of students' journeys to achieve the long white coat when they become "real" doctors.

Some articles try to convince us to abandon the white coat. Studies have shown that it could prove dangerous—in addition to white coat hypertension—as a possible way to spread infection after exposure to bacteria, viruses, or different pathogens. Some pediatricians and psychiatrists choose not to wear white coats because they believe their patients may feel overwhelmed by the perceived excessive authority demonstrated by the white coat.

However, other studies indicate just the opposite. A review of 4,000 patients at 10 U.S. academic medical centers found that a physician's clothing affects how patients view their doctor and how satisfied they are with their care. Physicians who wore a white coat over business attire (navy blue suit and dress shoes) were deemed more knowledgeable, trustworthy, caring, and approachable, particularly by older patients. Doctors who wore scrubs with a white coat scored next highest, followed by those in business attire with no coat. The exceptions were doctors in the operating and emergency rooms, where patients preferred doctors in scrubs.

In the past two decades, there has been a deterioration in the lofty status physicians once held. After the recent pandemic, there is an erosion of our patients' trust and confidence in the entire healthcare profession. Perhaps it is time to turn back the clock and suggest that doctors return to the day when the white coat created an excellent first impression that we want to help our patients with their medical problems and demonstrate compassion and empathy.

The most recognized symbols associated with the healthcare profession are the caduceus, the stethoscope, and, of course, the white coat. Like most doctors, I will not forget the moment when, as a medical student, I put on a white coat. It was as if all that studying and hard work paid off. As a practicing doctor, I spent most of my career wearing scrubs as I shuffled between the OR and the office to avoid changing clothes multiple times daily. I later learned at the recommendation of my staff that this was not only unprofessional but violated hospital policy by not changing scrubs after leaving the surgery area, going to the office, and then returning to the OR. Physicians wearing scrubs will wear a white coat when leaving the surgical area. I observed that fewer physicians wear a dress shirt, a tie, and a white coat today. Like many things in medicine, the COVID pandemic may have changed our patients' perspectives. This blog explores the issue of physician appearance and beckons the question of whether appearance still matters.

Except for a priest's clerical white collar, no workplace clothing contains as much symbolism as a doctor's white coat.

The white coat stands for professionalism, integrity, and the highest commitment to caring for our patients. While 97% of medical schools have a white coat ceremony, the use in clinical settings varies considerably between institutions and specialties. Pediatricians and psychiatrists have been more vocal about avoiding white coats because patients find them threatening.

A large study of 4000 patients at the University of Michigan found that a physician's clothing affects how patients view their doctor and how satisfied they are with their care. Those doctors who wore a white coat were deemed more knowledgeable, trustworthy, caring, and approachable, particularly by patients 65 and older. Doctors who wore scrubs with a white coat scored next highest, followed by those in business attire with no coat. An exception is that in both operating and emergency rooms, patients preferred doctors in scrubs.

There is ample evidence that white coats harbor dangerous microbes. Doctors, including medical students, residents, and fellows, might not launder their coats regularly to remove pathogenic bacteria and viruses. Doctors typically wash their lab coats once every 12 days, and only 70% of physicians admit to ever laundering their neckties. The longer we wear white coats, the higher the risk of hospital-acquired infections we are bringing to our patients. White coats might be safer if doctors laundered their coats more often.

White coat alternatives may also help with the century-old "white coat syndrome." First documented in 1896, experts have long known anxiety about doctors can cause high blood pressure readings. Please don't think that white coat hypertension is a benign condition. A mortality study found the risk of death is twice as high for patients with white coat hypertension as it is for those with normal blood pressure.

An alternative is the team vests with the doctor's name, which are now worn instead of a white coat. The vests have short sleeves, provide warmth when it's cold outside, and have pockets, which are necessary for physicians.

Bottom Line: So, will the white coat vanish anytime soon? The decision comes down to personal preference and the hospital's culture and the institution where the physician practices. It's true that many patients expect doctors to wear a white coat. The white coat remains the symbol of a physician's expertise and authority. It is an honor to wear a white coat, and we have all worked hard to earn the right to wear this important medical symbol. I doubt patients select their doctor if they wear or don't wear a white coat. So, I will leave the decision up to each doctor. I would be interested in your opinion on the white coat, and I can be reached at doctorwhiz@gmail.com

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.