Our large hospitalist group (22 FTEs) just implemented a dress code that requires the men to wear a tie at all times while seeing patients, even on weekends. In this era of many businesses allowing their workers to dress more casually, do you think it is necessary for doctors to always dress so formally?

—Samir in Seattle

Dr. Hospitalist responds:

You bring up an interesting topic, one that causes dissention in most large HM groups and has many roots: age, gender, professionalism, cleanliness, and culture are just a few. After all, it was Hippocrates who said a physician should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” Of course, Mrs. Smith’s allergies have forced us to get rid of the “unguents.”

Since the late 19th century, traditional (predominantly male) physician attire has been a white coat with formal suit or shirt and tie. The major push for a more professional look was medicine’s movement out of the realm of quackery and into the theatre of science. Once germs were found to be the cause of many of the illnesses responsible for killing people, the white coat and professional look came to represent cleanliness and authority. Who can forget the famous paintings of the late 19th century, such as “The Agnew Clinic,” which depicted surgeons operating with white smocks and the amphitheater full of medical students in three-piece suits?

Still, the physician most people picture (especially in the U.S.) wears the white coat with a shirt and tie if male, or a dress if she is female. More recently, television has anointed scrubs as the official attire of all hospital-based physicians, even though many institutions outlaw them outside of the operating room.

Many businesses in the U.S. allow less formal dress at work (i.e., casual Fridays). And the chorus sings: We are not in business; we are members of a profession! We take an oath to distinguish ourselves and espouse a standard of professionalism that is necessary to earn the trust of patients. As hospitalists, we typically don’t have established relationships with our patients, and those first impressions are priceless.

The U.K. prohibited wristwatches, long sleeves (including white coats), and dangling ties in 2007. Even though there was no epidemiological evidence to support such a move, the public saw physicians as carriers of infectious bugs. As international travel makes our world smaller, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Klebsiella pneumoniae Carbapenemase, and Clostridium difficile are increasingly prevalent and virulent in the hospital. Who can blame a suspicious public? I can’t.

Many of our patients grew up in an era when anyone flying by commercial air dressed in their Sunday best. It meant you were important or doing something important, and physicians have traditionally dressed the part. Most of our hospitalized patients today are older and more likely to prefer a physician in professional attire.

But who can forget the uproar in 2004, when an Israeli medical student tested the neckties of doctors and clinical staff at the New York Hospital Medical Center of Queens and found that nearly 50% were infested with potentially pathogenic bacteria. Most of organized medicine didn’t give the study much credence, because there was no evidence that the ties were directly tied to disease and most of the organisms were fairly ubiquitous.

Authors of a study published in The American Journal of Medicine in 2005 explored the impact of physician attire on patient confidence. Four hundred patients and visitors to a VA clinic were shown four sets of photos of doctors in different forms of attire (i.e., business attire, professional attire, scrubs, and T-shirts with jeans). Across all respondents, 76% of people chose the doctor in professional attire, followed by scrubs (10%), and business dress (9%).