How Podiatrist Attire Influences Patient Perspectives of Care
A positive patient-physician relationship is essential to appropriately provide medical care. Previous studies have shown the association between greater treatment satisfaction, adherence and persistence.1 While many components contribute to professionalism, how a physician dresses is often the first observation a patient makes during an encounter. With the ever-changing social constructs of society, the social perception of physicians' appearance continues to change.2
Hochberg explains that a white coat is a symbol of respect as well as a standard of professionalism and caring.3 However, previous studies have shown mixed results regarding patients’ opinions on a doctor’s use of white coats. In a study from Norway, 51.9% of patients did not want their doctor to wear a white coat, especially in younger populations.4 On the contrary, a study by Rehman and colleagues found 76.3% of respondents from a Veterans Affairs hospital favored professional attire with a white coat.5
Recently, studies emerged that examined attire based on the physician’s specific role (ie, surgeon and proceduralists versus primary care providers). In a literature review by Petrilli and colleagues, the authors looked at 30 studies with 11,533 patients.6 They found either no preference or preference for scrubs in procedural specialties. A recent article by Xun and colleagues, found that a white coat and scrubs was preferred for surgeons and a white coat with business attire was preferred for dermatologists and family physicians.7
While previous studies have looked at traditional physicians (MD/DO), no studies that we are aware of specifically looked at podiatric physicians and their attire. Podiatric physicians are unique as they often provide routine care similar to that of a primary care provider, but they also perform many in-office procedures like a proceduralist and provide surgical consultations. The aim of our current study is to look at a patient's perspective of podiatric physicians’ attires.
A Closer Look at the Study
The study was approved by our facility’s Institutional Review Board. Completion of the survey served as consent of participation. Information was provided to all survey participants on intent and potential of risks. We distributed the survey (Figure 1) at 2 podiatrists’ offices associated with an academic hospital with patients from 3 of the senior authors. Surveys were optional and provided to patients prior to the encounter with the attending podiatrist to help reduce bias based on what the attending physician wore that day.
The survey, as seen in Figure 1, included brief demographic questions regarding gender, age, and experience in the health care field. A 5-point Likert scale was used to determine if they prefer their podiatrist and primary care providers to wear a white coat, scrubs, fleece-blended sweaters or vests, softshell jackets, or no preference similar to the structure of the survey by Xun and colleagues.7 Additional questions were then asked about their preference on health care attire based on the type of encounter the podiatrist provided (routine care, procedure, and surgical consultation), their preference in attire for their primary care provider, and their preference in attire for the medical assistant (MA) or nurse.
Summary statistics, including means and standard deviations for continuous measures and frequencies and proportions for categorical outcomes, were calculated for all study variables. To assess the relationship between age and the outcomes of interest, Kruskal-Wallis tests were used; for categorical measures, such as gender and whether the respondent or family members worked in the health care field, Fisher’s exact tests were used. P-values < .05 were assumed to be statistically significant. SAS (version 9.4, Cary, NC, USA) was used for all analyses.
Our study included 208 participants at two locations. The average age was 56.7 +/- 16.3 years old. The respondents were 125 females (60.4%), 80 males (38.7%), and 2 identified as other (<1%). Three physicians’ patients at 2 locations were included in the study, both clinics are associated with the same academic hospital. There were 59 patients (28.4%) from Davie Clinic and 149 patients (71.6%) from Highland Plaza Clinic. No statistical significance was found between patient responses from the different locations. Table 1 provides the overall averages in responses for each category. Table 2, Table 3, and Table 4 show the responses in attire preference based on age, gender, and health care experience respectively.
The survey asked patients their preference on attire for nurses or medical assistants. In the clinics in the study, either a nurse or a medical assistant brings patients to the room, takes vitals, and collects preliminary information for the provider. The majority (75.26%) prefers the medical assistant or nurse to wear scrubs, as seen in Table 1. There was a statistically significant difference between age groups with a younger average respondent preferring scrubs over professional attire (P = .015) as seen in Table 2. There was no statistical difference between preference in attire for the nurse or medical regarding age or health care experience.
What Attire Did Patients Prefer for DPMs?
The survey asked patients what they prefer the podiatrist wears based on the encounter (evaluation, office procedure, or surgery consultation). Table 1 shows the most common response was that attire “does not matter” regardless of the type of encounter. The second most preferred option for a podiatrist completing an evaluation is professional attire with a white coat (26.9%). When seeing a patient for a surgical consultation or an office procedure, the second most preferred option is scrubs and a white coat, 24.8% and 32.5% respectively. There was statistical significance between age groups in responses for podiatrist attire when performing an office procedure (P = .0094) and a surgery consultation (P = .0092) as seen in Table 2. Respondents favoring a fleece jacket were more likely to be younger. There was a statistically significant difference between male and female responses for when a podiatrist comes in for an office procedure (Table 3) with only women (n = 5) choosing the preference of professional attire with a fleece sweater.
The survey participants were asked if they prefer their podiatrist to wear a tie. Following this question, they were asked if they thought ties were unsanitary. The majority (74.9%) of respondents stated it did not matter if a podiatrist wore a tie. Twenty-one percent stated they prefer podiatrists to not wear a tie and 4.5% stated they prefer the podiatrist to wear a tie. The majority (55.9%) of participants reported they are unsure if a tie is unsanitary followed by 33.3% believing a tie is sanitary. There was a statistically significant difference (P = .018) between health care and non–health care workers’ responses on the sanitation of ties. Health care workers and previous health care workers had a larger percentage responding that ties are unsanitary compared to non-health care workers (Table 4). There was no statistically significant difference in responses between ages or gender.
Participants were asked their preference in attire for their primary care provider. Almost half (49.8%) reported it did not matter. The second most common response was professional attire and a white coat (31.5%). There was no statistically significant difference in responses among ages, gender, or health care experience.
Evidence in the Literature for Health Care Attire
This is the first study to our knowledge that looks at patient perspectives on podiatric physicians’ attires. While studies have been created previously on different MD/DO specialties, podiatrists are unique in that to some patients they may provide more routine evaluations while for others they are performing complex surgical procedures.6–8 Overall, we found the plurality of participants selected that attire “does not matter.” Followed by this response, participants prefer scrubs and a white coat for surgical consultations and office procedures. For evaluations, respondents reported no preference followed by professional attire with a white coat. There were few respondents who preferred a fleece jacket. Our findings are supported by Petrilli and colleagues, who found no preference or preference for scrubs in procedural specialties.6 Xun and colleagues also found that respondents prefer white coat outerwear with scrubs inner wear for surgeons.7 This supports our study’s findings as all three of our senior authors are surgical podiatrists.
Our study found that the plurality of respondents did not have a preference on what their PCP wore followed by preferring family physicians to wear professional attire and a white coat. This is similar to what was previously published by Xun and colleagues, which found patients prefer white coat outwear with business inner wear for family physicians and dermatologists.7
Previous studies have looked at the relationship between age and preference for attire. Anvik and colleagues found significant differences between age groups with an increase in preference for white coats with older populations.4 They found 35% of patients in their 20s and 30s preferred a doctor in a white coat and the eldest about 70% were in favor of a white coat. Our study found statistical differences in ages in preference in medical assistant and nurse attire, podiatrists performing office procedures, and podiatrists providing a surgical consultation. Table 2 shows a trend with younger average age in fleece jacket preference and older average age in white coat preference. However, other studies have shown no correlation.8
Our study also asked patients about their perspective of ties being sanitary. Landry and colleagues found information regarding coat-carried infections did not influence respondents’ opinions.8 The majority of the respondents report tie wear does not matter and they are unsure if it is sanitary to wear a tie. The second most common response was that participants do not prefer their podiatrist to wear a tie. Fewer than 5% of respondents prefer podiatrists to wear a tie. Our study did find a statistically significant difference between health care workers and non–health care workers in their response regarding the view of ties being unsanitary or sanitary. Health care workers had a larger percent to respond that ties are unsanitary than non–health care workers. We recommend further studies evaluate the tie bacteria load and sanitary status.
One limitation to the study was the survey included 4 images: 1 female wearing a white coat and scrubs, 1 male wearing professional attire with a white coat, 1 male wearing scrubs with fleece-blending sweaters or vests/soft jacket, and 1 male wearing professional attire with fleece blended weather or vests/soft jackets. Xun and colleagues found regardless of the outerwear, female models were rated less professional than their male counterparts.7 Rehman and colleagues found that female attire was more important to respondents than male physicians’ dress.5 Not including images of females and males in each dress attire may negatively impact our results.
Another limitation is we did not ask respondents their race in the demographic section. There may be discrepancies between preference in attire by race or cultural backgrounds that were not analyzed in this study. Some previous studies have looked at this influence. Chang and colleagues found no difference in opinion between Western and Asian medical doctors.9 We recommend future studies regarding different cultural backgrounds and race.
All of the patients who responded to the survey were treated by surgical podiatrists. This may be a limitation to our study as it may not be as applicable to non-surgical podiatrists. However, we tried to minimize this bias by asking preference on attire based on encounter type. For non-surgical podiatrists, we recommend professional attire with a white coat. Another limitation is that both clinics the survey was distributed at is associated with an academic hospital. Future studies should expand on patient preference based on practice setting.
In Conclusion
We found the majority of patients have no preference in podiatrist attire. For those who did have a preference, white coat and scrubs was preferred for surgical consults and office procedures while professional attire was preferred for evaluations. This is supported by previous literature based on MD/DO specialties.6,7 However, this may be difficult to implement into practice as many podiatrist days have a mixture of encounters. We recommend wearing white coats with either professional attire or scrubs with no ties and no fleece jackets. We recommend future studies regarding the bacteria on ties being worn in health care settings.
Bryanna D. Vesely, DPM, MPH, is a resident physician in the Department of Orthopaedic Surgery at Wake Forest Baptist Medical Center in Winston Salem, NC.
Brennan K. Reardon, DPM, is a resident physician in the Department of Orthopaedic Surgery at Wake Forest Baptist Medical Center in Winston Salem, NC.
Cody D. Blazek, DPM, is an attending physician in the Department of Orthopaedic Surgery at Wake Forest Baptist Medical Center in Winston Salem, NC.
Ashleigh W. Medda, DPM, is an attending physician and Assistant Director in the Department of Orthopaedic Surgery at Wake Forest Baptist Medical Center in Winston Salem, NC.
Nicholas S. Powers, DPM, is an attending physician in the Department of Orthopaedic Surgery at Wake Forest Baptist Medical Center in Winston Salem, NC.
No author has a conflict of interest or has received any funding associated with this study.
References
1. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. doi:10.2147/PPA.S24752
2. Blumhagen DW. The doctor's white coat. The image of the physician in modern America. Ann Intern Med. 1979 Jul;91(1):111-6. doi: 10.7326/0003-4819-91-1-111. PMID: 88917.
3. Hochberg M. The doctor’s white coat—an historical perspective. Virtual Mentor. 2007;9(4):310-314. doi: 10.1001/virtualmentor.2007.9.4.mhst1-0704.
4. Anvik T. Doctors in a white coat--what do patients think and what do doctors do? Scand J Prim Health Care. 1990 Jul;8(2):91-4. doi: 10.3109/02813439008994937. PMID: 2218160.
5. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor's attire on the trust and confidence of patients. Am J Med. 2005 Nov;118(11):1279-86. doi: 10.1016/j.amjmed.2005.04.026. PMID: 16271913.
6. Petrilli CM, Mack M, Petrilli JJ, Hickner A, Saint S, Chopra V. Understanding the role of physician attire on patient perceptions: a systematic review of the literature—targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015 Jan 19;5(1):e006578. doi: 10.1136/bmjopen-2014-006578. PMID: 25600254; PMCID: PMC4312788.
7. Xun H, Chen J, Sun AH, Jenny HE, Liang F, Steinberg JP. Public perceptions of physician attire and professionalism in the US. JAMA Netw Open. 2021;4(7):e2117779. doi:10.1001/jamanetworkopen.2021.17779
8. Landry M, Dornelles AC, Hayek G, Deichmann RE. Patient preferences for doctor attire: the white coat's place in the medical profession. Ochsner J. 2013;13(3):334-342.
9. Chang DS, Lee H, Lee H, Park HJ, Chae Y. What to wear when practicing oriental medicine: patients' preferences for doctors' attire. J Altern Complement Med. 2011 Aug;17(8):763-7. doi: 10.1089/acm.2010.0612. Epub 2011 Jul 1. PMID: 21721926.
