Respond to this article

Head to Head: Should medical schools have a say in how medical students dress?

Deborah Bowman says that what you wear has no bearing on your ability to practise medicine, but Daniel K Sokol argues that it is an important mark of professionalism

YES I am writing this on a plane, flying over the mountains of New Zealand. The captain walked to the plane in a smart dark suit and cap. On the public address system his voice was soothing and self assured. My life and that of the dozens of passengers on board are in his hands. His appearance, his walk, the tone of his voice, and his words inspire confidence. If he had been wearing torn jeans and a T shirt, stumbled on his way to the cockpit, and spoken with a meek and trembling voice, I would be anxiously reading the safety instruction card rather than composing this article.

Quick judgments

The truth is that I don’t know the first thing about flying an aeroplane. I therefore make judgments about the pilot based on external factors. Similarly, most patients know little about medicine and so form an opinion of their clinician based on appearance, demeanour, reputation, speech, gestures, and other qualities and actions. The brevity of most doctor-patient interactions also calls for quick judgments on the competence and likeability of a doctor—and of course doctors also make rapid assessments of their patients. Most of the time there simply isn’t time for each to get to know the other.

Because patients probably evaluate clinicians in the first few seconds of the interaction and because most encounters last only a short time, it seems sensible to identify the elements that affect patient evaluation, and if these can be changed with little cost and effort to adjust them in ways that would put patients at ease. Sick patients have enough to worry about without wondering if their clinician is competent and trustworthy.

The way we dress shows a lot about ourselves. That is why we are so picky when we buy clothes and why buying clothes for others is a delicate business. It also explains why guides recommend dressing smartly for job interviews. Even before a word is spoken, a well dressed candidate suggests that he or she is meticulous, respectful, and serious about your job. This close relationship between self and dress is translated, in the patient faced with the odd or scruffy looking medic, into something like “How can this medical student take care of me if she can’t take care of herself?”

Professionalism requires acting in certain ways, and because many patients are sensitive to attire this includes wearing appropriate clothing. Sporting baggy jeans and a baseball cap at a clinic may be expressing your true self, but it is a failure of professionalism. Professionalism and individualism might clash yet this is not necessarily bad. Professionalism can entail suppression of self, rather than a celebration of individuality—a call for uniformity rather than heterogeneity. This is perhaps most evident among professional military personnel, where stepping out of line can result in the death of colleagues, but it also applies to medics. For example, an exasperated doctor may want to tell a non-adherent patient to “bloody well get a grip,” but professionalism requires a more composed and less overtly judgmental approach. Allowing medics to “be themselves” through dress and behaviour, although more liberating and comfortable for some, may adversely affect the perception of their patients and more generally the way the public view the medical profession.

Degree of freedom

Although the scope for sartorial individuality is reduced by dress codes, it is rarely eliminated. Even if I have to wear jacket and tie, I can still choose which jacket and tie to wear, for example. There remains some degree of freedom. The imposition of certain rules of dress is hardly a costly sacrifice, unless it clashes with deeply held religious convictions. It is, for people who like to dress informally, at worse a nuisance. Such is the cost of professionalism. Outside working hours, medics, pilots, lawyers, and other professionals can wear anything they want—or indeed nothing at all.

Aside from a possible reduction in public trust in medics, what are the harms of socially inappropriate attire for medical students? Most obviously there is the potential distress, especially older or more traditional patients, who may be taken aback by a ghostly white figure walking towards them dressed in black from head to toe (a goth student) or by a doctor with a constellation of glittering piercings on his eyebrows, tongue, lips, and ears. It is unlikely to cause huge anguish, but it is unsettling none the less, and if, in the words of the UK General Medical Council, you should “make the care of your patient your first concern,” then perhaps we should put limits on what medics can wear. This obligation would fall under the general principle of non-maleficence, or not causing harm to patients. Indeed, the experience may be so off-putting for patients that, to avoid examination by this particular medical student, the worried patients diplomatically decline to have any student participate in their care. The student’s training will be affected by this refusal, but importantly so will the training of his or her peers, who will be denied an opportunity to learn. The harms extend beyond the individual to colleagues and ultimately to the profession as a whole. The harmful consequences of a liberal position on clothing is not an individual matter but affects others too. This is a powerful argument against the abolition or relaxing of dress codes.

The captain has just announced we are landing in Rotorua. All electronic equipment must be switched off. I shall do as he says: he’s an awfully good pilot.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

See Deborah Bowman’s argument against, http://student.bmj.com/issues/09/03/life/93.php.

See “Medical dress: a history,” http://student.bmj.com/issues/09/03/life/94.php, and “Medical student fashion,” http://student.bmj.com/issues/09/03/life/89.php.

Where do you stand on the issue? Let us know by leaving a rapid response.

Daniel K Sokol lecturer in medical ethics and law St George’s, University of London, London SW17 0RE
daniel.sokol@talk21.com
Student BMJ 2009;17:92 | March

NO Dress codes for medical students are becoming increasingly common. What is the rationale for such guidance? Are instructions on what is “appropriate” an unwarranted form of social control? Is there ethical justification for requiring students to dress to an externally determined standard?

Consider the case of Carla, a goth, who has a very white face and dresses all in black. She is a medical student entering her third year. She has, to date, been largely based in educational settings, although she has made a few clinical visits. Carla is able and has consistently been in the top 10% of her cohort. She is committed to medicine, contributes to volunteer groups, and has never given any cause for concern.

Clara’s appearance

Before term starts, Carla’s tutor asks to see her and somewhat awkwardly explains that she has been asked to raise the matter of Clara’s appearance before she begins work on the wards.

Is the medical school justified in asking Carla to change her appearance? Most people will probably react to Carla’s appearance; even if merely to note that she looks different. Does that intuitive response to difference warrant a request to change? On what moral basis might the case be made for Carla to alter her usual dress?

Clothes are commonly imbued with moral force in medicine. Trust, competence, authority, and respect have all been associated with dress. The most common example of clothing being imbued with moral status is the white coat. “White coat ceremonies,” where a senior clinician bestows the white coat upon medical students have been debated in the United Kingdom,¹ although in these times of meticillin resistant Staphylococcus aureus the value of the white coat has diminished somewhat. It is the symbolism of the white coat, and particularly the ritual of the ceremony, that is usually seen as morally beneficial.² Although others have suggested that the white coat can be elite, distancing, and lead to default authority rather than earned trust.³

Given that patients, students, doctors, and academics will have diverse views on dress codes, how can we move the debate on from subjective judgments about Clara’s appearance? Firstly, consider the inherent worth of homogeneity: what is the case for uniformity of uniform? Medical socialisation and students’ efforts to show suitability for, and membership of, the “club” are well documented.⁴ Might professional norms stifle independence, inhibit diversity, and prevent future doctors from engaging with the wide population they will serve? The socioeconomic profile of medical school entrants remains narrow.⁵ Might there be a case for celebrating heterogeneity rather than quashing it? The medical profession is regrettably characterised by its encompassing demands and stressful nature.⁶ Could the very small step of allowing people to be themselves, encouraging plurality, and fostering a culture of tolerance reduce doctors’ over-representation in the divorce, addiction, and mental illness statistics?

What are the possible consequences of Carla’s sartorial choices, acknowledging the limits of predicting outcomes? Might Carla’s dress harm relationships with patients and public perception? Is there evidence to suggest that patients prefer doctors and, by extension, medical students to dress a particular way? In the limited literature available, patients seem to prefer that male doctors don’t wear earrings,⁷ jeans, or have long hair,⁸ and they dislike facial piercings on all doctors.⁹ They prefer semiformal to formal attire and, reassuringly perhaps, a smile is most valued.¹⁰

Perhaps Carla’s appearance has implications for relationships with patients, but the “evidence” is equivocal and does not support prohibiting Carla from dressing as she wishes to avoid harming these relationships or compromising trust. Carla has much to offer, and most patients would surely prioritise her knowledge, skills, and conscientiousness over her clothes.

Self directed adaption

The response of the tutor should be to raise the question of how Carla’s appearance may be received. Carla is likely to be used to curious stares and has probably experienced mixed reactions to her appearance. As a thoughtful and committed student, Carla can reflect on the variables that shape an effective medical student-patient relationship. Most students spend the initial period on the wards wondering where they fit in and how to maximise their experience. Carla will be doing likewise, and self directed adaption to the clinical environment is preferable to faculty induced, unquestioning conformity.

Although dress is often associated with moral value or deficit, such associations often merge assumption and generalisation rather than considered analysis. Attention to the question of homogeneity in medicine moves discussion beyond the subjective absurdity of skirt lengths, make up, or hairstyle. Evidence about the effects of dress is limited and culturally specific. Carla is an exemplary student—she is capable, altruistic, and conscientious. Is it professionalism or tribalism that is at play? At the very least, all in medical education should consider the question properly even though the eventual conclusion is that Carla will need a new wardrobe.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

See Daniel Sokol’s argument for, http://student.bmj.com/issues/09/03/life/92.php.

See “Medical dress: a history,” http://student.bmj.com/issues/09/03/life/94.php, and “Medical student fashion,” http://student.bmj.com/issues/09/03/life/89.php.

Where do you stand on the issue? Let us know by leaving a rapid response.

Deborah Bowman lecturer in medical ethics and law Centre for Medical and Healthcare Education, St George’s, University of London
dbowman@sgul.ac.uk
Student BMJ 2009;17:93 | March

1. Gillon R. White Coat Ceremonies for New Medical Students. J. Med. Ethics 2000; 26: 83 – 84; Veatch R. M. White Coat Ceremonies: A Second Opinion. J. Med. Ethics 2002; 28: 5-6; Huber S. J. The White Coat Ceremony: A Contemporary Medical Ritual. J Med Ethics 2003; 29(6): 364-366; Glick S. M. White Coat Ceremonies – Another Commentary. J. Med. Ethics 2003; 29: 367 - 368.
2. Branch W. T. Deconstructing the White Coat. Annals of Internal Medicine 1998; 129(9): 740-742.
3. Wear D. On White Coats and Professional Development: The Formal and the Hidden Curricula. Annals of Internal Medicine 1998; 129(9): 734-737
4. Becker H. S., Geer B., Hughes E. C. and Strauss A. L. (1961) Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press; Mumford E. (1970) Interns: From Students to Physicians. Cambridge MA: Harvard University Press; Broadhead R. S. (1983) The Private Lives and Professional Identity of Medical Students. New Brunswick: Transaction Books; Hafferty F. W. (1991) Into the Valley: Death and the Socialization of Medical Students. New Haven: Yale University Press; Sinclair S. (1997) Making Doctors: An Institutional Apprenticeship. Oxford: Berg
5. Department of Health (2004) Medical Schools: Delivering the Doctors of the Future. London: Department of Health, 2004; British Medical Association (2004) The Demography of Medical Schools: A Discussion Paper. London: BMA, June 2004.
6. Massad S. (1993) Doctors and Other Casualties. Lincoln: iUniverse.com, Inc; Ghodse H., Mann S. and Johnson P. (2000) Doctors and Their Health. Sutton: Reed Business Information; West L. (2001) Doctors on the Edge. London: Free Association Books.
7. Gjerdingen D. K., Simpson D. E., Titus S. L. Patients’ and Physicians’ Attitudes Regarding the Physician’s Professional Appearance. Arch Intern Med. 1987; 147: 1209-1212.
8. McKinstry B., Wang J-X. Putting on the Style: What Patients Think of the Way Their Doctor Dresses. Br J Gen Pract. 1991; 41: 275-278.
9. Newman A. W., Wright S. W., Wrenn K. D. and Bernard A. Should Physicians Have Facial Piercings? JGIM 2005; 20(3): 213-218
10. Lill M. M., Wilkinson T. J. Judging a Book by its Cover: A Descriptive Study of Patients’ Preferences for Doctors’ Appearance and Modes of Dress. BMJ 2005; 331: 1524-1527.

      

 Printable version      Download PDF    E-mail this to a friend    Respond to this article    Request Permissions