An international study confirms that the doctor’s clothing represents a form of non-verbal communication capable of influencing the relationship with the patient
Every doctor remembers how in the first years of internship it was enough to wear a gown to be questioned by the relatives of hospitalised patients with questions instead of the nurses. Now there is scientific confirmation of this common experience: researchers from 20 hospitals and medical practises in Italy, Japan, the United States and Switzerland have published in the British Medical Journal the largest international study ever conducted regarding medical uniform.
Doctor’s clothing is apparently a form of non-verbal communication capable of influencing the relationship with the patient so that, even before the doctor opens their mouth, the patient understands from what they are wearing how well prepared and reliable they are and whether they will be considerate and helpful with them.
A good doctor-patient relationship is based on mutual respect, trust and acceptance of treatment by the patient, so it is essential to make them feel at ease when discussing their personal problems. The strength of this relationship has a direct impact on their satisfaction with health care, impacting their health through greater adherence to treatment recommendations, leading to a decrease in relapses within 30 days of discharge and even a reduction in mortality rate.
The research sample
Under the direction of Sanjay Saint and Nathan Houchens of the University of Michigan, 15 international researchers collected the opinion of over 9,000 patients on the clothing of those who treated them in three types of institutions: university hospitals, general practices or clinics, and specialist facilities. Spanning 13 geographical areas, 4 countries and 3 continents they observed that, based on the place of residence, opinions change based on the gender and age of the patients, as well as their level of education.
The first age group of the interviewees ranged from 18 to 64 years and the second was 65 and over. The latter group constituted over a third of the total (36%) with variations from country to country: in Japan, for example, those aged 65 or over were 48.5%, while in Italy they were 27.8%. Almost half of the patients were women (44.9%), many of whom had a diploma or degree (39.6%).
The study was conducted by distributing a form with 22 questions in the local language and photos of a male or female doctor in various types of clothing on which they were asked to express their preference. The doctors photographed had unchanged expressions with consistent framing, lighting, background, pose, etc. To avoid the so-called anchoring phenomenon whereby the first choice influences the subsequent ones, the gender of the doctor in the first photo was randomly assigned. Evaluations were based on a scale of 1 to 10 with which patients could express the value that clothing inspired in them in five categories:
They were later provided 7 photos of the same doctor with various types of clothing and patients had to choose the most suitable for various clinical contexts: the general practice, the emergency room, the hospital ward, the surgical theatre, etc. These preferences were evaluated with the Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).
The responses of patients showed that, although the lab coat is universally considered the symbol of the medical profession, what is underneath the lab coat also counts and it is precisely on this that the choices of patients differ. Italians and Japanese, for example, agree on almost everything, but under the gown, Italians prefer serious and sober formal clothing such as a shirt and, in the case of a female doctor, a blazer with trousers or a skirt. Formal clothing is the absolute favourite of American patients, even without a lab coat.
Things change in Switzerland where patients, in addition to casual clothing, like to see the characteristic green or blue scrub tunic under the gown that we are more used to seeing on surgeons in operating rooms. Scrub uniforms got the most patient preference for ER doctors (44.2%) and surgeons (42.4%). The survey highlighted different preferences depending on the doctor: for hospital patients, the scrub jacket is in fact preferred not only by Swiss patients, but also by Italian patients who, moreover, like it in 8.8% more cases.
Patients do not appreciate extreme clothing which is too casual or too elegant: the double-breasted and bow tie under the coat can inspire excessive detachment and little empathy. Colleagues Sanjay Saint and Nathan Houchens have been dealing with these aspects of assistance for some time, collaborating above with many Swiss centres.
Professor Saint has also raised awareness from the WHO on the expectations that patients have regarding the clothing of their doctors. Although these vary according to socio-cultural norms, context and individual personality, in some cases such as for doctors in the emergency room and for surgeons, they are almost universal. But if preferences vary, a tailored approach that matches medical clothing to its context helps cultivate a relationship with the patient that increases patient satisfaction, confidence, expectations, and health outcomes.
The impact on care outcomes
In a 2019 study, Portuguese researchers directed by Joao Firmino-Machado of the University of Porto showed how the appearance and behaviour of the doctor can improve the age-old problem of compliance, and acceptance of therapy. The patient’s expectations towards the doctor and the perception they have of them are constantly linked to how the doctor presents themself to the patient. Presentation was underlined by researchers at the Harvard Medical School in Boston in 1987, when they called for the development of deontological guidelines for decorum in professional clothing to improve patient satisfaction which resulted in improvements to medication adherence and clinical outcomes.
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