Ontario, Canada (Fall 2016)
What doctors wear influences their image.1-3 Vestments act as powerful symbols; they are especially important, it has been argued, when the occupant of the symbolized role is new to it. The less sure a new physician is about his or her professional role, the more critical it is to be seen as embracing it fully, ostentatiously displaying its trappings. The theory is that the paraphernalia of office are essential to the act of self-completion, the full realization of one’s newly acquired status.4 That is why young physicians wear white coats, prominently display their diplomas, expose their stethoscopes, liberally use Latin phrases, and boast in public about their difficult “cases.”
White was not always the doctors’ color. Physicians used to dress in black until the late nineteenth century, much as clergymen and lawyers still do. Black was considered appropriately solemn for solemn professions. The modern white coat was introduced to medicine by Dr. George Armstrong (1855-1933), a Canadian surgeon and one time president, of the Canadian Medical Association.5 Microrganisms had just been discovered and doctors needed to project a free of germs appearance, to look as pure and pasteurized as milk. By the time the twentieth century began, doctors around the world had changed their attire to white.
When I was a medical student in the 1950s, hospital personnel from physician to nurse to resident to medical student to ward clerk were all in white. They could nevertheless be easily distinguished one from another by what they wore. Staffmen (and women) wore starched knee-length, white lab coats with large pockets to house the obligatory stethoscope; residents and interns wore white trousers (or skirts) with white high-collar tunic shirts that buttoned down the side. Only surgeons wore green scrubs. Medical students were provided with short white jackets (with large pockets) to wear over everyday clothes. Nurses had a complicated system of status identification with hats, badges, collars, cuffs, belts, stripes, and piping (differing from hospital to hospital) reflecting rank.6 The nursing uniform remains a contested topic to this day.7 Outfits are visible symbols intended to make it easy for all to know where occupation and hierarchy boundaries are drawn8 but, as with all borders and barriers, there are those who chafe against them.
Wicklund’s self-completion theory, mentioned above,4 does not fully explain why we wear what we wear. Clothes fulfill a need in the wearer but they also influence, and powerfully so, viewers’ responses. For instance, it has been shown that formal dress exacts obedience.9 It has been likewise shown that no one will intrude on your personal space if you dress formally.9 The white lab coat, which can be considered as the formal wear of physicians, is preferred by most patients on most surveys10,11despite the fact that the cuffs of the long white sleeves are home to germs.10,12,13 From a cleanliness standpoint, the rule nowadays for doctors is ‘bare below the elbow’ – no sleeves, no swinging tie, no long hair or beard, no bracelet or watch at the wrist.10
When I was an intern in the 1960s (in my skirt and top whites), a second year resident (in his trousers and tunic whites) spotted a man in the nursing station wearing a short white jacket and looking through a patient chart. This resident enjoyed teaching, and he was a good teacher, so he asked the student in the short white jacket:
“Have you seen the patient yet?”
“I haven’t had a chance to yet, doctor. But I did see the X-Rays.”
“That’s no way to learn, my good fellow. You can’t be looking up films and charts before you see the patient. That’s not the way you were taught, is it? First, you see the patient with no preconceived ideas in your mind and only then you go to check the chart to see how your findings match the test results. That’s the only way to learn. That’s right, close the chart. But now that you’ve seen the X-Ray films and the tests results, what would your plan of attack be? What do you think should be done now, doctor?”
“I’d do a thoracotomy, doctor.”
“Whoa now. That’s all very well for you to say, but back up, first tell me what you think he has, what the differential is and the treatment you’d advise for each possibility. Get organized. And better not come out with thoracotomy so fast or I might just ask you how you’d go about doing one and what the contraindications are and you’d be stuck, my friend. And don’t put your feet up on the desk when I’m talking to you.”
The nurse-in-charge managed at that point to whisper in the resident’s ear, “That’s not a medical student. That’s Dr. Michael Bach, the visiting staff surgeon from Liverpool.”
Consultants usually wore business clothes but, of course, they could wear anything they pleased. This particular one had chosen a short white coat. Coming from Liverpool, he would not have been aware of our local dress code14 or maybe he was, and chose to flout it.
Today, doctors are divided on the white-coat question. Only about one in eight actually wear one at work, and this is not only to avoid hygiene hazards. The coat can cause ‘white coat hypertension’ – patients’ blood pressure soaring as soon as a white coat approaches.15 It can alienate some patients by accentuating the power differential between doctors and patients.9 It can make an already self-important doctor feel even more so.16 A stated advantage, however, is that wearing a white coat helps doctors maintain a proper professional distance from their patients – helps them not to cross sexual boundaries.17 Joseph and Alex18 have shown that uniforms not only reinforce boundaries but also serve as constant reminders of physicianly responsibilities. When healers wear white, they are unconsciously prodded to be19 angels in white, “White, withouten spot or pride” (Edmund Spenser, The Faerie Queen) and “White as utter truth” (Alfred Tennyson, Gareth and Lynette).
- Blumhagen DW. The doctor’s white coat: The image of the physician in modern America. Annals of Internal Medicine, 1979;9:111-116.
- Furnham A, Chan PS, Wilson E. What to wear? The influence of attire on the perceived professionalism of dentists and lawyers. Journal of Applied Social Psychology 2014;4:1838–1850.
- Hochberg MS. The doctor’s white coat – an historical perspective. Virtual Mentor, 2007;9:310-314.
- Wicklund RA, Gollwitzer PM. Symbolic Self-Completion. Abingdon-on-Thames: Routledge; 2013
- Agrawal R. The withering shine of white coat. Annals of the Indian Academy of Neurology, 2012;15:63.
- Bates C. Looking closely: Material and visual approaches to the Nurse’s uniform. Nursing History Review, 2010;18:167-188.
- Johnson KKP, Yoo J-J, Kim M, Lennon SJ. Dress and human behavior: A review and critique. Clothing and Textiles Research Journal, 2008;26:3-22.
- Shaw K, Timmons, S. Exploring how nursing uniforms influence self image and professional identity. Nursing Times, 2010;106:21–23.
- Timmons S, East L. Uniforms, status and professional boundaries in hospital. Sociology of Health & Illness, 2011;33:1035-1049.
- Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price LS, Murthy R, Palmore T, Rupp ME, White J, Expert guidance: Healthcare personnel attire in non-operating room settings. Infection Control Hospital Epidemiology, 2014;35:107-121.
- Landry M, Dornelles AC, Hayek G, Deichmann RE. Patient preferences for doctor attire: The white coat’s place in the medical profession. The Ochsner Journal, 2013;13:334-342.
- Naik TB, Upadhya A, Mane V, Biradar A. Microbial flora on medical students’ white coat and an analysis of its associated factors: A cross sectional study. International Journal of Current Microbiology and Applied Sciences, 2016;5:353-363.
- Mitchell A, Spencer M, Edmiston C Jr. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. The Journal of Hospital Infection, 2015;90:285-292.
- McCracken GD, Roth VJ. Does clothing have a code? Empirical findings and theoretical implications in the study of clothing as a means of communication. International Journal of Research in Marketing, 1989;6:13-33.
- Martin CA, McGrath BP. White‐coat hypertension. Clinical and Experimental Pharmacology and Physiology, 2014;41:22-29.
- Johnson K, Lennon SJ Rudd N. Dress, body and self: research in the social psychology of dress. Fashion and Textiles, 2014;1:1-24.
- Nadelson C, Notman MT. Boundaries in the doctor–patient relationship. Theoretical Medicine and Bioethics, 2002;23:191-201.
- Joseph N, Alex N. The uniform: a sociological perspective. American Journal of Sociology, 1972;4:719–730.
- Adam H, Galinsky AD. Enclothed cognition. Journal of Experimental Social Psychology, 2012;48:918-925.
MARY V. SEEMAN, M.D. is Professor Emerita in the Department of Psychiatry at the University of Toronto. She did her internship at Harper Hospital, Detroit in 1960.