Xun H, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.17779.

Xun H, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.17779.

In a recent survey, patients said they viewed physicians in casual attire such as a fleece jacket in place of a white coat as less professional and less experienced.

The findings, published in JAMA Network Open, also revealed that casual clothing led to misidentification of roles, particularly among female physicians, and that female physicians were often rated as less professional than their male counterparts, even when wearing a white coat.

“The findings of the study suggest that female physicians are less likely than male physicians to be identified as physicians and more likely to be misidentified as nurses, medical technicians or physician assistants,” Jordan P. Steinberg, MD, PhD, of the department of plastic and reconstructive surgery at Johns Hopkins University School of Medicine, and colleagues wrote. “This misconception may be associated with prevailing stereotypes.”

Despite a shift in the U.S. health care workforce, most physicians are still men (604,560 men vs. 293,120 women), whereas most nurses are women (3.2 million women vs. 330,000 men), according to the researchers.

“The public’s increased exposure to male physicians and female nurses contributes to the formation of gender-based professional stereotypes and associated biases,” they wrote.

Steinberg and colleagues conducted a population-based survey through the Amazon Mechanical Turk platform from May 2020 to June 2020. The survey cohort was comprised of 487 adults in the U.S. The mean age of respondents was 36.2 years; 53.4% were women; 76.4% identified as white and 6.8% as Black.

The respondents provided answers on a five-point Likert scale about where and how often they see health care professionals wearing white coats, scrubs, fleece-blended sweaters or vests and softshell jackets, and the most important attributes in a health care professional: experience, professionalism or friendliness.

Respondents also ranked on a six-point Likert scale the experience level, professionalism and friendliness of professionals in a series of photographs that showed models wearing various health care attire. Their preferences for health care attire were based on a professional’s role, which included nurse, technician, phlebotomist, family physician, dermatologist and surgeon.

The majority of respondents reported seeing health care practitioners in white coats “most of the time” (42.5%), in scrubs “sometimes” (36.6%) and in fleece and softshell jackets “rarely” (37%), according to the researchers. While a practitioner in a white coat was perceived as more experienced (mean professionalism score: 4.9 for white coat vs. 3.1 for fleece jacket vs. 3.3 for softshell jacket; P < .001), a practitioner in a softshell jacket appeared more friendly to respondents (mean friendliness score: 3.6 for white coat vs. 3.1 for softshell; P < .003).

Older respondents were significantly more likely than younger respondents to perceive a model in a white coat with business attire underneath as having more experience (P < .009). Also, Steinberg and colleagues reported that fleece jackets with scrubs underneath reduced professionalism scores for all regions in the U.S. except the West. Most respondents reported a preference for surgeons wearing a white coat with scrubs underneath and, for family physicians and dermatologists, a white coat with business attire underneath (P < .001).

When comparing men and women, respondents perceived a male model wearing business attire with any outerwear item as significantly more professional than a female model wearing the same attire (mean professionalism score: 65.8 for men vs. 56.2 for women). When shown photos of models wearing only hospital or fashion scrubs, respondents still perceived the male model as more professional than the female model (P < .001). Moreover, male models in white coats with business innerwear were more likely to be identified as a physician than female models in the same attire (88.3% for men vs. 71.7% for women; P < .001), according to Steinberg and colleagues.

“The white coat still has powerful symbolism, and ‘white coat ceremonies’ continue to be a rite of passage for medical students. Our study seems to indicate that, despite this, the white coat does little to address the problems of role misidentification and gender bias, particularly as (a) more and more clinical personnel these days may be offered white coats to wear, and (b) many hospital or office personnel have come to prefer casual wear,” Steinberg told Healio Primary Care. “In the COVID-19 era, where there again is heightened emphasis on disinfection, infrequently laundered white coats may also be disfavored.”

He added that the research team suspected that gender bias and physician role misidentifications would persist “irrespective of formal vs. casual wear.”

In a related editorial, Amalia Cochran, MD, FACS, an associate professor of surgery at University of Utah Health Care, and Gilbert R. Upchurch Jr., MD, a professor of surgery and chairman of the department of surgery at the University of Florida College of Medicine, weighed in on the longevity of the white coat culture in medicine. The history of the white coat dates back to the latter part of the 19th century, though resistance to it has mounted over the last 20 years, according to Cochran and Upchurch.

“Although public perceptions related to expertise may still favor white coats, perceptions of expertise also still widely favor older male physicians. It is therefore intriguing that for women physicians, no clear benefit to the patient-physician relationship can be attributed to wearing a white coat,” they wrote. “This work still does not help us to unravel the relationship, if any, between patient biases and clinical outcomes. Perhaps the message embedded in the article by Xun et al is simply that the white coat’s importance is primarily symbolic and that it is no longer a prerequisite for physicians to provide high-quality and compassionate clinical care.”

Cochran A, Upchurch GR. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.19881.

Xun H, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.17779.

As the delivery of care has evolved in the U.S. health care system, there has been an anecdotal shift in some settings towards less professional wear. This study surveyed a small group of individuals on their impressions of physicians wearing varying types of attire.

The respondents surveyed perceived a white coat to align with more experience and professionalism. It was interesting but not surprising that women wearing business attire as inner wear were seen as less professional than their male counterparts, and the women were more likely to be misidentified as a technician, physician assistant or nurse. This gender disparity is consistent with what we have seen reported in numerous studies, that women are more likely to be seen as other members of the team and not identified as physicians. Male models, regardless of clothing choice, were perceived as more professional than female models wearing the same attire. While all models in white coats with business inner wear were more frequently identified as physicians, the male model was more likely to be identified as a physician than the female when wearing the same clothing. These findings were statistically significant.

This type of misidentification has happened to me personally many times, regardless of the clothing I am wearing underneath my white coat. I do make a point to correct patients, colleagues and other individuals in the hospital and in the clinic to let them know that I am a physician. There are several reasons why I feel this is important.

Patients should know who they are speaking to and who they are getting information from. If I speak to them about the plan of care and they later believe that a physician has never spoken to them, that is a problem. I want to ensure that my patients know that I am a physician so they know the plan that is being discussed is being discussed by the physician who is taking care of them.

When it comes to colleagues or others in the hospital, I will also make sure that I am correctly identified because, again, it’s important to know who you’re speaking to when you are speaking to a member of the team because you need to know where the information is coming from. Especially in front of mentees and trainees, I want to emphasize that it’s extremely important to address female and male physicians in a consistent manner. If you’re referring to one gender by their professional title and another gender by a nonprofessional title, that is a problem for a variety of reasons. First, it diminishes the expertise of the female physician if she is not being addressed in the same manner as her male colleagues. Second, it can be very demoralizing for female physicians when they are constantly being misidentified as a different role or position, and that can lead to burnout, disillusionment and frustration with their positions. And third, it’s professional to make sure that you are referring to physicians by their title, especially in front of patients in clinical settings. So, I encourage my team to be consistent in how they are addressing physicians, whether they identify as male or female.

I personally do wear a white coat regularly and I do it for a several reasons. It’s an easy way to carry my stethoscope and other things that I might need, especially as a woman where if I’m wearing a professional dress, I oftentimes do not have pockets. So, wearing a white coat for me is to some extent a level of convenience. I also wear a white coat because I think it helps identify me as a physician in some cases. The challenge now is the white coat is being worn in many hospitals by many people who aren’t physicians so it can sometimes be confusing for patients when everyone is coming in with a white coat. But I also make sure my ID badge is visible and I introduce myself as “Dr. Jain” while wearing my white coat, so I feel wearing the white coat provides that second layer of professionalism when interacting with patients. I do also take a great deal of pride in the fact that I went through the white coat ceremony and worked hard to earn the privilege of being a physician to my patients. So, for me, it’s a convenience issue and my hope is that it also helps patients identify who I am in certain situations.

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