eMJA: Harnett, Should doctors wear white coats?

The Profession

Should doctors wear white coats?

Paul R Harnett

MJA 2001; 174: 343-344
For editorial comment, see Van Der Weyden

The wearing of white coats by hospital doctors is becoming a rarity, making it difficult for patients to identify doctors from other hospital staff. I asked patients with cancer whether they thought that doctors, both junior and senior, should wear white coats. Only a minority disapproved.

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Asking the patients - Patients' responses - Discussion - Acknowledgements - References - Authors' details
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The white coat is a well established symbol of the medical profession. In more than 90 medical schools in the United States its symbolism is recognised by formal ceremonies at which students are awarded the "right" or distinction of wearing a white coat to emphasise the humanistic values of medicine.^1,2 Among the many recent changes in the way medicine is practised, one little-studied change has been the addition of "white-coated" doctors to the "endangered species" list in many hospitals. Although some relatively isolated pockets of this species remain, their numbers continue to decline. In many hospitals they are now so rare as to prompt comment, if not amusement, when observed by chance "in the wild".

Subtle societal changes have been proposed as a reason for the demise of white-coated doctors -- modern-day patients may find the use of a white coat to be an inappropriate status symbol or a barrier to effective communication. In particular, in paediatric practice it has been suggested that white coats may be an impediment, although studies have failed to confirm this.^3,4

I investigated the phenomenon of the disappearing white coat doctors in my environment by asking oncology patients about their attitudes to doctors and white coats. I was prompted to do this by remarks from patients indicating that identification of doctors and nurses in hospitals was an issue of concern.

Asking the patients

Patients attending the oncology outpatient clinics of three Sydney hospitals in September and October 1999 completed a short questionnaire about whether junior and senior doctors in hospitals should wear white coats. Patients could "agree", "disagree", or respond "I don't care". They could give reasons for their choice either by agreeing with suggested options ("for identification purposes", "looks more professional" or "for reasons of hygiene"), or by free-text response.

Patients' responses

Questionnaires were returned by 180 patients (47 men, 113 women [20 did not specify their sex]; age range, < 20-90 years [32 did not give their age]). Only 153 patients responded to questions about senior doctors, which were on the reverse side of the page.

Junior doctors

106 respondents (59%; 95% CI, 52.8%-67.2%) agreed that junior doctors should wear white coats; 17 disagreed (9%; 95% CI, 4.8%-13.2%), and 57 patients (32%; 95% CI, 25.2%-38.8%) responded " I don't care". The same general pattern was seen for both men and women.
Reasons for agreeing (46 respondents): "for identification purposes"(41); "looks more professional" (36); and "reasons of hygiene" (6).
Reasons for disagreeing (31 respondents): white coat a barrier to communication between doctor and patient (10); wearing a coat was a choice for the individual doctor (6); and avoiding additional cost.

Senior doctors

61 respondents (40%; 95% CI, 32.2%-47.8%) answered that senior doctors should wear white coats; 32 disagreed (21%; 95% CI, 14.5%-27.5%) and 60 (39%; 95% CI, 31.3%-46.7%) said "I don't care".
Reasons for agreeing (28 respondents): white coats look more professional or assist in identification (22); and hygiene (3).
Reasons for disagreeing (34 respondents): not wearing white coats distinguishes senior doctors from junior doctors, and white coats distance doctors from patients (11).

Patients who preferred junior doctors to wear white coats were also likely to prefer senior doctors in white coats. The proportion of patients disagreeing with doctors' wearing white coats reduced significantly with advancing patient age (P = 0.01, by logistic regression analysis).

Discussion

A clear majority of respondents thought that junior doctors should wear white coats (only 9% disagreed), but the situation was less clear for senior doctors, with roughly equal numbers of respondents either agreeing that senior doctors should wear white coats or indicating they didn't care. Our results contrast with the current practice in many Australian hospitals (including those I work in) where junior doctors no longer wear white coats.

Many respondents who supported the wearing of white coats for junior and senior doctors agreed that white coats looked more professional or assisted in identification. Interestingly, reasons related to infection control or hygiene were uncommon. Of the 20% of respondents who disagreed with white coats for senior doctors, most referred to white coats as being some sort of a barrier.

As with all questionnaires, the data are potentially subject to bias. The number of questionnaires distributed was not recorded, making it impossible to exclude bias from an unbalanced sample. Patients who declined to complete the survey may have had a preference for, or against, the wearing of white coats. However, anecdotal evidence from hospital staff is that patient refusal to participate was rare.

That the doctors at the hospitals surveyed do not wear white coats could influence patient responses. Perhaps patients did not express stronger support for senior doctors' wearing white coats for fear of displeasing their attending doctor. If so, our data would underestimate patients' preferences for senior doctors' wearing white coats.

Many patients raised the issue of white coats with their doctor after completing the questionnaire. This feedback indicates that identification of hospital staff is a significant problem for patients, magnified by degrees of debility and dependence. Patients often have difficulty distinguishing the relative roles of staff wearing corporate uniforms (ie, nurses, clerical staff, kitchen staff, etc); name tags were difficult to read and insufficient for identification. Similar studies of patients' views of non-medical apparel in hospitals may be instructive.

If, from the patients' perspective, the greatest usefulness of the white coat is its value as a rapid means of staff identification, then to simply recommend reintroduction of white coats may be premature, especially if an alternative, effective means of staff identification can be implemented.

I do not believe that the results would be greatly different in other Australian settings, and recent reports from international clinical settings suggest qualitatively similar results.^5,6 Our findings confirm that the clinical environment and medical interaction are complex, and that individual patients hold differing views. However, our data do not suggest that the clinical environment has changed to one that favours extinction of white-coated doctors.

Acknowledgements

Thanks are due to colleagues in the Department of Medical Oncology and Palliative Care at Westmead, Blacktown and Nepean Hospitals. The data management input by Shoma Barat is appreciated. Special thanks are due to the patients who offered their views for this study.

Competing interests: None.

References

Branch WT Jr. Deconstructing the white coat [editorial]. Ann Intern Med 1998; 129: 740-742.
Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med 1998; 129: 734-737.
McCarthy JJ, McCarthy MC, Eilert RE. Children's and parents' visual perception of physicians. Clin Pediatr (Phila) 1999; 38: 145-152.
Matsui D, Cho M, Rieder MJ. Physicians' attire as perceived by young children and their parents: the myth of the white coat syndrome. Pediatr Emerg Care 1998; 14: 198-201.
Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract 1998; 15: 391-397.
Ikusaka M, Kamegai M, Sunaga T, et al. Patients' attitudes toward consultations by a physician without a white coat in Japan. Intern Med 1999; 38: 533-536.

Authors' details

Department of Medical Oncology and Palliative Care, Westmead Hospital, Sydney, NSW
Paul R Harnett, MB BS, FRACP, PhD, Director of Cancer Services, Westmead and Nepean Hospitals.

Reprints will not be available from the author.
Correspondence: Dr P R Harnett, Department of Medical Oncology and Palliative Care, Westmead Hospital, Westmead, NSW 2145.
harnettprATwestgate.wh.usyd.edu.au