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Wednesday Nov 06, 2019

Should Appearance Matter in Medicine?

A recent survey(www.mdlinx.com) asked U.S. physicians about their shoe preferences, and it turns out doctors have some extremely strong opinions about footwear.

[Circle of feet wearing different shoes]

Ninety-nine percent of respondents said their choice of shoes was important or very important. Out of eight factors physicians were asked about, cost (22%) was the least important consideration and appearance (53%) ranked fourth behind three issues related to comfort and support.

When we asked our new physician bloggers for their opinions on the survey results, the conversation quickly broadened to one that encompassed attire, appearance and professionalism.

Do Your Clothes Spark Joy?

I love that someone cared enough to ask doctors what kind of shoes we prefer. Even if the most common reported reasons for shoe choice are practical and not aesthetic, it makes me happy to know that someone realizes that we have preferences about how we, as physicians, look.

The survey reminded me of a medical school friend who chose to wear fashionable high heels on a daily basis. I envied her ability to present herself in the way that she wanted. I wondered whether smart, serious people even had the luxury of choosing to look nice. Watching my friend pull it off was inspiring. For many years, shapeless trousers and collared shirts were the mainstay of my professional attire. As a woman in medicine who wanted to be taken seriously, that's what I thought I was supposed to wear. Seeing my medical school friend was the first moment where I felt like I could enjoy pretty things, even while at work.

Society's messages for both men and women and how they should dress are confusing, and in the past, I placed far too much importance on the idea that presenting yourself as smart and competent meant that there was no room for appearing "pretty." The reality is that there is not one single way a smart and competent physician "should" dress because serving as a physician is a part of our whole being. Our appearance, instead, should be an expression of who we are, while coloring (somewhat) within the lines of societal expectations. A dyad, if you will, instead of a dichotomy.

During the past few months, I've been more deliberate about what I choose to wear. I've donated baggy clothes that don't "spark joy." (Yes, I was on the KonMari bandwagon.) I've actively moved toward feminine dresses, flattering sweaters and shoes that are both comfortable and -- dare I say it? -- cute. It's been freeing, in a way, to accept that my appearance and my womanhood don't detract from how seriously I take myself as a physician. I can only hope that others appreciate that sense of wholeness as much as I do.

Lalita Abhyankar, M.D., M.H.S., New York City

Yes, I Do Want Scrubs

I am a family physician, so I can't easily predict what I'm going to do for my patients throughout the day. In the hospital wards -- in residency -- we would round on a patient admitted for pneumonia or heart failure and seemingly out of nowhere be paged to the labor-and-delivery floor to check on an obstetric patient. I've since stopped delivering babies (malpractice insurance + hospital politics = my head exploded), but I still can't predict who will show up to my outpatient clinic and what care they'll need. For example, yesterday we had everything from an IUD removal/insertion to well-child checks to a couple of phone calls checking in about kids with fevers. I've had patients show up unannounced with lacerations and broken bones. I've only had one GI bleed show up in office -- so far.

I realized scrubs serve a really important function because I can't predict when putting my patient first will mean putting my clothing second. I'm never in an OR, but sometimes my little clinic -- and ER work -- gets messy.

So, I wear scrubs to work. They're OR scrubs, not the cutesy, expensive ones marketed to health care professionals. They're designed to be thrown away, and sometimes I do throw them away. I recently had a gentleman (we'll call him a gentleman) in the ER spit a mouthful of blood in my face, on my chest, in my hair and on my arms. Thanking heaven that I was wearing glasses and had my mouth closed, I calmly walked to the call room, peeled off my scrub top, tossed it aside (and later into the biohazard trash), and washed my face, arms and hair under warm, soapy water.

I run my own clinic, which means I'm also out in the community meeting with business leaders. Sometimes -- often when I forget about business meetings and the need to wear business attire -- I end up at these meetings in scrubs. Before I can apologize for my attire, I often get a sideways look and comments like, "You look so official!" or "You look like a doctor!"

Which is, of course, true. I am a doctor. I wear scrubs not because I'm acutely thinking about how people perceive me or if I'm viewed as professional. I wear them because I am a professional and I need to do my job without second thoughts about my clothes. Because I'm a family physician.

Allison Edwards, M.D., Kansas City, Kan.

White Coat Conundrum

Whether you view the white coat as a symbol of prestige or healing or you cringe at the thought of how many germs reside in it, this article of clothing carries a lot of meaning -- and mixed feelings. I remember the joy of donning the garment for the first time one cold day in October, the weekend after finishing our first anatomy exams. Unlike many medical schools, our students' white coats looked exactly like those worn by residents, fellows and attending physicians. The length of my sleeves did not give away my role as a medical student trainee, and I found great comfort in that. My hesitation in providing answers may have revealed my training level, but my clothes did not.

Now, when I see patients in my own clinic, the symbolism and power of the white coat is not lost on me. Although doctors and other medical professionals disagree on what is acceptable attire in the clinic or in hospital hallways, it is clear that it does matter to patients. A survey of more than 4,000 patients(www.ncbi.nlm.nih.gov) showed that a little more than half said a doctor's outfit was important to them and more than one-third said a doctor's attire influenced their satisfaction with the care experience. Although there are differences by region, specialty and gender, I do not think it changes the fact that what we wear has influences on patient encounters.

I'm not advocating for a hard-and-fast rule on attire. People will continue to agree to disagree whether the white coat establishes a detrimental power dynamic or provides reassurance. I think what it calls for is awareness. Our clothing choice, although it does not dictate what we know or how we operate, leaves an impression. And although the cover may not dictate what the book contains, realizing its impact may make you think twice about whether to wear a white coat.

Astrud Villareal, M.D., D.I.M.P.H., Dallas

Consider the Coffee

Before I started my third-year medical school rotations, I visited my uncle who worked in a shoe store with the specific goal of purchasing the brand of clogs that I had come to associate with being a doctor. They seemed versatile (I could wear them in the OR and with nice slacks), comfortable and durable. It turns out they were a great choice, and I only recently bought a new pair (more because I was excited about a new pattern and less because the old ones were no longer functional).

But there was one unfortunate moment during residency when they were absolutely the wrong shoe choice.

It was a dark, cold winter morning in New York. We had just experienced an enormous snowfall. I was exhausted, and the only way I managed to get myself out of my cozy, warm bed was the thought of a large, also warm, cup of coffee from across the street. But as I exited my building wearing scrubs and clogs, I almost cried when I saw the enormous banks of snow on both sides of the street that I would have to cross. The hospital (and its inferior coffee) was on the same side of the street as I was, and there were no snow barriers preventing me from walking my clogged feet into another day of residency -- and that second-rate coffee.

Margaux Lazarin, D.O., M.P.H., Redwood City, Calif.

Putting the "Man" in "Manicure"

One of the things I enjoy about being married to another family physician is the conversations we share during dinner each night. Usually we tell each other about our day in clinic or the hospital. My husband frequently mentions interesting patient interactions, including patients' responses to seeing his painted fingernails for the first time. He can tell the moment they notice because no matter the age, gender, race/ethnicity or sexual identity, all of his patients pause a moment when this happens.

The reactions range from compliments, to preoccupation, to a question from one young boy who asked, "Why are you wearing girl nails?"

Although these reactions don't impact his ability to care for patients or the flow of his day on a large scale, they are deeply important to him. As a member of the LGBTQ community and a physician, his nails are a constant reminder to him and to his patients that he represents a larger community. LGBTQ patients face more barriers to health care and health disparities compared with their heterosexual peers.(www.aamc.org) For many LGBTQ patients, the simple act of having a family physician who is openly queer can be welcoming and empowering. But this also could be an important experience for patients who are uncomfortable with his painted fingernails. A recent study showed that 34% of Americans ages 18 to 34 were uncomfortable finding out their physician was LGBTQ,(www.usatoday.com) up from 27% the year before. This is an opportunity for an open and honest discussion and for patients to associate a trusted physician with a community they might otherwise not interact with.

As my husband said to the young boy, "Boys can have pretty nails, too."

Kyle Leggott, M.D., Aurora, Colo.

Conversation Starters

I first showed my tattoos in clinic accidentally. As a resident, I was often sleep-deprived, and one sunny, post-call day I showed up in scrubs. My sleep-addled brain had forgotten that scrubs were short-sleeved. I had intentionally gotten my tattoos in places that were not usually seen when wearing sweaters or button-up shirts, my standard clinic attire (with bow tie, of course).

I suddenly started sweating because although there was no rule against visible tattoos for physicians at my residency, my patient panel was full of older, mostly conservative people. I love them dearly and did not want to ruin the therapeutic relationship I had carefully cultivated.

The first comment I received was from my third patient that day, an older gentleman who I knew from a church I had tried out early in my time in Klamath Falls, Ore. He took in my tattoos, asked who did them and launched into a story of his time in the Korean War that included showing me his own tattoo. This was the first of five positive conversations that day, which also included a teenager telling me she didn't realize I was that cool and looking at me with newfound admiration, as well as a young mother who exclaimed excitedly, "I LOVE Calvin and Hobbes!" when she saw the famous duo staring at the night sky partially hidden beneath the too-short-to-hide-the-whole-tattoo shirt sleeve.

I know that those who dislike tattoos are likely to just stay quiet, but I have subsequently been shocked by how many stories, laughs and connections they have engendered. I still usually wear a sweater to work because it's cold in my office, but on the days I let my tattoos breathe, I usually leave the office with a smile, surprised at the conversations I never would have had otherwise. This is not a reason to go out and get your first tattoo, but I have learned that, at least in this profession, there is no particularly strong prohibition.

Stewart Decker, M.D., Klamath Falls, Ore.

Dress the Part

I think one's personal choice of dress code comes down to our biggest influences and whom we model ourselves after. When I was growing up, my parents didn't have any tattoos or piercings and required us to dress up for school and church. From a young age, I was inspired to become a physician by older family doctors who looked the traditional part, with beards, glasses, cardigans, dress slacks and leather shoes.

My understanding of professionalism has always been that you should present an image of being serious and focused on your job, thus assuring others that you have achieved and maintain a high level of competency. It is about looking the part and avoiding appearances that would detract or distract from the message you are trying to send and the job you're trying to do.

As a rural family physician focused primarily on adult and geriatric medicine, I am keenly aware of the population I serve, and I realize that cultural and generational biases will influence their perception of what a doctor should look like. I think it is important to understand and respect your audience, so I do my best to present myself accordingly. Of course, it makes it easier when your own personal aesthetic values match those of the people you serve.

I always try to put myself in my patients' shoes and imagine how my appearance will impact their experience when I am encouraging lifestyle modifications, providing counseling or delivering news of a serious or potentially terminal diagnosis. I wore a Halloween costume last week for the sake of taking the expected holiday photos with my staff, but I returned to my normal dress code for patient visits. That being said, it was perfectly acceptable and appropriate for my costumed staff to provide my patients with a laugh and a smile before their encounters with me. None of my patients asked where my costume was, which I think sheds light on their expectation of my professionalism.

Ultimately, I say, to each their own. As a family physician providing continuity care, your patient panel will inevitably evolve through self-selection to match your personality.

Kurt Bravata, M.D., Buffalo, Mo.

Posted at 08:45AM Nov 06, 2019 by Lalita Abhyankar, MD, MHS

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