It’s a question more and more physicians are asking–scrubs or no scrubs? Dr. Ashley Trotter and Dr. James Kim share their opinions on the topic.

Have We Gotten Too Casual?

By Ashley Trotter, MD

Dr. Trotter

Before the COVID-19 pandemic, I remember physicians standing out not only for their presence and composure but for their professional appearance. In suits, dress pants, blouses, and sharp jackets, I remember my former attendings and colleagues making an entrance. There was no question who the doctor was, or who was in charge of the patient’s care. Out of necessity, with an unknown deadly virus decimating our ranks, those snappy outfits were replaced by surgical scrubs, designed to withstand the high heat and daily washing that we all hoped would give our families a chance to avoid the same exposures we had to endure.

Over time, those scrubs became trendier. More colorful. Softer. They became daily wear for most, and a fashion statement in and of themselves. Colleagues would compare their collections, proudly displaying the new limited-edition colors they had just snapped up. Comparing brands and styles became the water-cooler talk (if there was still a shared water cooler). Brands would rise and fall as scandals and missteps arose, but the scrub trend did not seem to slow down. Suddenly, scrubs were the new norm for daily rounds, even outside of COVID-19 units, and when the fleeting discussion about the appropriateness of such dress would come up, more often than not the subject would quickly change, or the glances would be anywhere but on the one bringing that topic to a head. The convenience was desirable. Bodily fluids were less of a concern. Dressing in the morning was quicker and simpler.

However, perhaps it is time we rethink the casual workspace. As we physicians strive to distinguish ourselves from other health care professionals, we should not forget how much presentation matters. As many of us women physicians fight the stereotypes placed on female practitioners of, “Oh my nurse is here!”, and as we fight to be seen for who we are, it raises the question: Have we gotten too casual?

Dr. Ashley Trotter is an academic hospitalist at NorthShore University HealthSystem in Evanston, Ill. As the teaching chief for hospital medicine, she manages continuing medical education for the division, primarily through her faculty education series. Additionally, she is an associate program director for the University of Chicago NorthShore internal medicine residency program.

Heels, White Coats, Formal Wear, and Scrubs

A brief history of fashion and health care attire

By James Kim, MD

Dr. Kim

The evolution of what is considered appropriate attire within a society often comes about via cultural exchanges or major historical events. For example, high-heeled shoes were invented in Persia in the 10th century. They were originally worn by noblemen to make them appear taller and for convenience when riding horseback (the heels clicked into the stirrups). In the 17^th century, Persian royalty visited the French court, and the style quickly spread among men in European high society.¹

Around the same time, women often adopted “masculine” elements in their fashion to achieve some of the social benefits they accrued.¹ So as high heels propagated in men’s fashion, they soon spread to women as well. Men later largely abandoned high heels,² but the style persisted in women and so, at this time, high heels are considered to be primarily women’s fashion.

As far as medical attire is concerned, physicians primarily wore black clothes like members of the clergy until the late 1800s. In the U.S., a more widespread association of white coats with physicians started around 1889 with Joseph Eakins’s painting “The Agnew Clinic.” In it, Dr. Agnew and his assistants are depicted wearing white coats while performing surgery. One could surmise that the white coat invoked a feeling of precision and cleanliness in contrast to the “snake oil” and quackery that was often seen during the Victorian era. For this and various other reasons, white coats continued to spread as part of the “standard uniform” for physicians throughout the 20^th century.³

Like the evolution of high heels, however, the demographics of those who wear white coats have shifted. Many health care professionals besides physicians wear white coats, which is a change from what I remember during my training in medical school (2000-2004). In my institution, I have seen advanced practice providers, respiratory therapists, social workers, physical therapists, and occupational therapists (to name a few) wear white coats regularly. To borrow a linguistics term, the white coat (signifier) no longer correlates with an individual being a physician (signified).

Further, it is no exaggeration to say that the COVID-19 pandemic was a significant event in world history that has affected commerce (e.g., increased automation, online purchasing platforms), social mores (e.g., social distancing, mask-wearing), education, and countless other areas of society. Many tendencies and trends that were noted before the pandemic accelerated tremendously as a response to the new reality, and health care attire is no exception.

Even before the pandemic, there was an ongoing debate about whether to change the “standard” white coat with formal attire garb for a “bare below the elbows” (BBE) dress code. While there are multiple studies showing contamination of scrubs, white coats, and ties, “no clinical studies have shown cross-transmission from a health care provider to a patient via apparel” and there is no definitive evidence that BBE attire on inpatient providers improved nosocomial infection outcomes.^4-5

Despite the lack of great evidence, guidelines suggest that facilities should consider BBE dress for inpatient care as an infection prevention adjunct based on biological plausibility and low likelihood of harm.⁴ I agree that anything that lowers barriers to proper hand hygiene is a good thing. For men’s formal wear, appropriate handwashing is possible in long-sleeved dress shirts, but getting the cuffs wet if you’re not careful with the water is a minor but real disincentive to thoroughly clean. Short-sleeve dress shirts are available, but I find them aesthetically unappealing. My feeling is that the pandemic was the nudge that pushed providers to wear scrubs regularly, and there is no going back for many.

As Dr. Trotter mentioned, women physicians, unfortunately, face an uphill battle with being acknowledged as physicians even when they’re in the same level of formal dress as men. One study noted that male and female models in white coats with business innerwear were most frequently perceived as physicians, but the male model was more likely to be identified as a physician than the female (88.3 versus 71.7%). When shown models wearing scrubs, participants most frequently identified them as surgeons, but male models were more likely than females to be identified as a surgeon (49.5% versus 40.7%, P=0.01); females in scrubs were more often perceived as a nurse than the male (33.1% versus 27.3% P=0.05).⁶

I have female colleagues in my group who wear more formal attire specifically so that they are more likely to be recognized by patients as the doctor. But for the most part in hospital medicine, we do not choose our patients, and our patients do not specifically choose us. We still have to care for patients in a professional manner even when they have prejudices and biases about us based on our gender, age, race, attire, and a variety of other parameters.

In the end, I feel that in the absence of definitive data, one cannot make an absolute prescription about what all doctors “should” wear. “Although patients frequently express preferences for certain types of attire, including white coats, they were willing to change their preferences when informed of potential risks associated with HCP [health care practitioner] attire. Patient comfort, satisfaction, trust, and confidence in their physicians is unlikely to be affected by practitioners’ attire choice, except for name tags, which they viewed as essential.”⁴

While I note my preferences for scrubs in this article, the next pandemic, natural disaster, or other major world events may change my preferences again. Though I have abandoned my white coat and formal attire for inpatient care, who’s to say that I may not take them up again with a short-sleeved dress shirt and heels? However, I do know that regardless of what comes next, during initial patient encounters, I will wear a name tag, attempt to shake the patient’s hand, and introduce myself as the doctor.

Dr. Kim is an associate professor of medicine, at Emory University School of Medicine, and a hospitalist at Emory University Hospital, Atlanta.

References

1. Segran E. The long history of heels: from a symbol of men’s power to women’s burden. Fast Company website. https://www.fastcompany.com/90775177/the-long-history-of-heels-from-a-symbol-of-mens-power-to-womens-burden. Published August 4, 2022. Accessed November 15, 2022.
2. Did you know men were the first to wear high-heel shoes? News 18 website. https://www.news18.com/news/lifestyle/did-you-know-men-were-the-first-to-wear-high-heel-shoes-2881163.html. Published Sept. 16, 2020. Updated Sept. 16, 2020. Accessed November 15, 2022.
3. Harrah S. The white coat ceremony – A rich tradition for medical students. University of Medicine and Health Sciences website. . https://www.umhs-sk.org/blog/white-coat-ceremony. Published February 17, 2021. Accessed November 15, 2022.
4. Palmer T, Bearman G. Guide to infection control in the healthcare setting: Healthcare personnel attire in non-operating room settings. International Society for Infectious Diseases website. https://isid.org/guide/infectionprevention/health-care-personnel-attire/. Last updated April 2018. Accessed November 15, 2022.
5. Mahoney, Sarah. The white coat: Symbol of professionalism or hierarchical elitism? AAMC News website. https://www.aamc.org/news-insights/white-coat-symbol-professionalism-or-hierarchical-elitism. Published July 21, 2018. Accessed November 15, 2022.
6. Xun H, Chen J, Sun A. Public perceptions of physician attire and professionalism in the US. JAMA Netw Open. 2021;4(7):e2117779. doi:10.1001/jamanetworkopen.2021.17779.