INTRODUCTION
The white coat remains a powerful symbol of the physician, despite dramatic changes in the medical field during the last century. Wearing a white coat during medical practice began in the late 1880s when surgeons began wearing white coats in their quest for new “aseptic” methods. By the beginning of the 20th century, the use of the white coat had spread to most physicians and was firmly established as the “doctor’s uniform.” The white color was specifically chosen to associate physicians with purity and cleanliness. White coats have been acknowledged as an integral part of physician dress. A study had shown that 36–80% of their patients preferred that their doctors wear the white coat. They accounted professionalism, easy identification, and hygiene as the reasons for their belief. Over the past two decades, there has been a declining use of the white coat, even in the hospital setting due to its capacity to harbor and spread infectious agents if not maintained properly.[ 1 ]
Many factors influence doctor–patient relationship, one of which is gender preference of doctors by patients. Even though women form 70% of workers in the health and social sector, an average gender pay gap of around 28% exists in the health workforce.[ 2 ] Thus, exploring this gender disparity from patient’s point of view is crucial.
The basis of the practice of medicine depends on a successful doctor–patient relationship and efforts should be made to build rapport to foster a partnership to provide patient-centered care. One approach is to understand how physician attire influences patients’ experience and develop guidelines based on their preferences. It has been established that for a good relationship and effective communication with the patients, a doctor’s attire and style of dressing play a very important role. However, there are conflicting literature findings regarding a doctor’s dressing style.[ 3 ] In previous studies, it was found that while patients preferred formal attire and white coats overall; scrubs or casual dress was preferred in specific settings.[ 4 ] Studies conducted in India have revealed a high preference for the white coat.[ 1 , 3 , 5 , 6 ]
Literature evidence provides many studies on patients’ perception of doctor’s attire around the world but there are limited studies available in India and no known studies were found to be done in Manipur. So, this study aims to assess the perception of patients toward doctors’ appearance and its influence on doctor–patient rapport.
MATERIALS AND METHODS
A cross-sectional study was conducted between January 2022 and February 2022 among patients aged 18 years and above attending the OPD of health-care centers in two districts (one urban and one rural) of Manipur. Patients from tertiary care hospitals from Imphal West district (urban) and district hospital, two community health centers, and two primary health centers from Bishnupur district (rural) were approached for the study. Patients who were medical professionals, seriously sick, and with psychological problems were excluded.
Sample size and sampling
Taking 88.7% prevalence of patients’ preference of their doctors wearing white coat with an absolute allowable error of 4%, a sample size of 250, was intended to be taken separately from each of the two districts (Imphal West and Bishnupur) giving a sample size of 500.[ 3 ]
Study tool and data collection
Data collection was done by interviewing those eligible participants who came to the OPDs using a pretested semistructured questionnaire which was prepared after a thorough review of the literature. It consisted of five parts: background characteristics, preferred background characteristics of the doctor (gender/age group), the preferred appearance of the doctor (nine statements with three responses: Yes/No/No preference), influence of doctor’s attire on patients’ perception (four statements based on 5-point Likert scale: Strongly Disagree to Strongly Agree), and overall preference of the doctor’s attire.
Statistical analysis
Data analysis was performed using IBM SPSS 26 for Windows (IBM, Armonk, NY, USA). Data were summarized using descriptive statistics like mean, standard deviation, frequency, and percentage. Association between independent and outcome variables was checked using the Chi-square test. A P value of <0.05 was considered to be statistically significant.
Ethical issues
Ethical approval was obtained from the Research Ethics Board, Regional Institute of Medical Sciences, Imphal (A/206/REB/Prop (SP) 165/140/02/2022). Informed verbal consent was taken from each participating individual. No names or addresses were taken to maintain confidentiality and data collected were kept secured and only assessed by the investigators.
RESULTS
A total of 544 participants were interviewed. The mean age of the participants was 36.40 ± 12.55 years. The majority of the respondents were females (60.80%) and were from a tertiary care center, Imphal West (64%).
Preferred background characteristics of the doctor
A majority (60.30%) had no preference for doctors’ gender. Of the 39.7% who had doctors’ gender preferences, comfortability in consulting with the same gender (66.7% for female doctors and 56.6% for male doctors) was the main reason for their preferences.
Table 1 shows that the majority of the participants preferred their doctors’ hair to be well groomed (87%), clean-shaven (77.8%), and worn ID/badge (82.9%). Most of the participants would bother if the doctor had tattoos (60.1%) and nails not trimmed (82.9%).
Table 1: Participants’ preferred appearance of the doctor (n =544)
Influence of doctor’s attire on patient’s perception
A percentage of 93.2 of the participants preferred their doctors to wear the white coat. A percentage of 45.4 of participants agreed that the doctors’ attire would make them seem more knowledgeable and competent while 25.2% disagreed with this. More than half of the participants agreed that the doctors’ attire would make them seem more trustworthy (52.6%) and approachable (52.9%). A percentage of 36.9 disagreed that doctors’ attire would make them seem more caring.
Tables 2 and 3 show an association between sociodemographic characteristics with an overall preference for doctors’ attire and gender preference, respectively. Participants from health-care centers in Imphal West had significantly more preference for the doctors’ attire to be a formal dress with a white coat (P = 0.04). Age group and education level were significantly associated with gender preference (P < 0.05). Male participants had significantly no preference for doctors’ gender (P = 0.01). Participants from rural health-care centers had significantly no preference for doctors’ gender (P = 0.00).
Table 2: Association between sociodemographic characteristics with the overall preference of doctors’ attire (n =544)
Table 3: Association between sociodemographic characteristics with gender preference (n =544)
DISCUSSION
Cultivating trust and creating a comfortable environment remain the key to establishing doctor–patient rapport. The prima facie image that the doctor creates in the mind of the patient is therefore important. So, it is important to assess the perceptions the patients have regarding doctors’ attire and outward appearance so that concerned authorities can implement appropriate policies to invigorate a successful doctor–patient relationship.
The study was conducted in both rural and urban settings to ascertain any differences in patients’ perceptions regarding doctors’ appearance. More than half of the participants were recruited from a tertiary health center. A percentage of 93.2% of the participants preferred their doctors to wear the white coat. A similarly high proportion of participants preferred the white coat in other Indian studies conducted by Singh et al. , Sachdeva et al. , and Aggarwal.[ 1 , 3 , 6 ] Singh et al . and Sachdeva et al. , in studies conducted in Punjab (2020) and New Delhi (2017), respectively, have reported that majority of the participants (88.7% and 54.9%, respectively) preferred their doctors to wear white coat.[ 1 , 3 ] Similarly, De Lott et al. ,[ 5 ] in a study conducted in the United States in 2015–2016, found that 52.3% of the participants preferred their doctors to be wearing formals with white coat. This may be because the white coat remains a symbol for the physician irrespective of the study settings.
In this study, around 60% of the participants had no gender preference for doctors. This is an encouraging finding and indicates a relative lack of prejudice against the patients based on gender. This is in line with findings of Alyahya et al .[ 7 ] and Dagostini et al. ,[ 8 ] where majority of participants had no gender preference regarding their physician’s attitude and professional competence. Female participants in this study were significantly more likely to have gender preference compared to males. Singh et al .[ 3 ] found that more than half of the participants preferred to consult a female doctor. The main reason for having gender preference was the easiness of consulting with doctors of the same gender. This is understandable as people may be more comfortable with sharing their grievances, especially ones with a sensitive nature, with others of the same gender. Patients from urban setting in this study were significantly more likely to have gender preferences compared to those from a rural setting. This may be because the more number of doctors in urban areas give patients the luxury to choose the gender of doctors they consult, whereas choices are limited in rural areas.
In this study, the majority of the participants preferred their doctors to be well groomed and clean shaven (87% and 77.8%, respectively). The latter may be due to the customary belief that clean-shaven males are self-disciplined, maintain more hygiene, and hence more professional. On the contrary, Yonekura et al .[ 9 ] found that only 26.3% of the participants were disturbed by doctors having facial hair. These differences might be due to differences in study setting and study population.
The majority of the participants also preferred their doctors to wear ID cards. It may be because an ID card may give subconscious reassurance to the patients that they are meeting a person with authority. Around half of the participants agreed that a doctor’s attire would make him/her knowledgeable, trustworthy, and approachable. Similarly, De Lott et al. , Petrilli et al. , Kamata et al. , and Reid et al . reported that doctors’ attire was important to the patient.[ 4 , 5 , 10–12 ]
Participants from urban setting preferred their doctors to wear white coats significantly more than participants from rural setting. In rural health-care system, doctor–patient relationship might be preestablished due to their proximity to community compared to urban health system where relationship is more formal.
Strengths
Data were collected from all levels of health-care centers from both urban and rural areas and are probably the first known study conducted in Manipur which will help in increasing the existing knowledge regarding the perception of patients toward doctors’ appearance.
Limitation
Convenience sampling was used so it may not be generalizable. The subjective nature of the questionnaire might have led to social desirability bias but it was addressed by asking participants to answer truthfully.
CONCLUSION
Three-fourths of the participant had no preference over the doctors’ gender. Three-fourths of the participant preferred doctors’ attire to be formal with a white coat. Doctor’s hair dye, facial piercing, and tattoos did not bother a majority of the patients attending tertiary care centers. Participants from urban health-care centers had significantly more preference for the doctors’ attire to be a formal dress with a white coat. Age group, gender, type of setting, and education level were significantly associated with gender preference.
RECOMMENDATIONS
Making use of white coats by doctors at all levels should be reinforced as it is a cost-effective intervention that will help build a robust doctor–patient relationship. Further education of the public on the limited role of doctors’ appearance affecting their actual treatment is the need of the moment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Sachdeva S, Tanja N, Dwivedi N. Patients preference for doctor attire in an outpatient department of a government hospital in New Delhi, India. MAMC J Med Sci 2018;4:88–92.
2. Boniol M, McIsaac M, Xu L, Wuliji T, Diallo K, Campbell J. Gender Equity in the Health Workforce: Analysis of 104 Countries. Working Paper 1. Geneva: World Health Organization; 2019 (WHO/HIS/HWF/Gender/WP1/2019.1). Licence: CCBY-NC-SA 3.0 IGO.
3. Singh R, Kaur A, Nandi J. Looks do matter:Patients'perspective. Int J Heal Clin Res 2020;3:13–7.
4. Petrilli CM, Saint S, Jennings JJ, Caruso A, Kuhn L, Snyder A, et al. Understanding patient preference for physician attire:A cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open 2018;8:e021239.
5. De Lott LB, Panarelli JF, Samimi D, Petrilli C, Snyder A, Kuhn L, et al. Patient preferences for physician attire in ophthalmology practices. J Acad Ophthalmol 2019;11:36–42.
6. Aggarwal R. The withering shine of white coat. Ann Indian Acad Neurol 2012;15:63.
7. Alyahya G, Almohanna H, Alyahya A, Aldosari M, Mathkour L, Aldhibaib, et al. Does physicians'gender have any influence on patients'choice of their treating physicians. J Nat Sci Med 2019;2:29–34.
8. Dagostini I CM, Bicca YDA, Ramos MB, Busnello S, Gionedis MC, Contini N, et al. Patients'preferences regarding physicians'gender:A clinical center cross-sectional study. Sao Paulo Med J 2022;140:134–43.
9. Yonekura CL, Certain L, Karen SK, Alcântara GA, Ribeiro LG, Rodrigues-Júnior AL, et al. Perceptions of patients, physicians, and Medical students on physicians'appearance. Rev Assoc Med Bras 2013;59:452–9.
10. Kamata K, Kuriyama A, Chopra V, Saint S, Houchens N, Petrilli CM, et al. Patient preferences for physician attire:A multicenter study in Japan. J Hosp Med 2020;15:204–10.
11. Reid DR, Makinde KA, Wilson MP, PausJenssen AM, Barton JW, Wilson TW. Dress and deportment of medical residents:Formal or informal?. Clin Invest Med 2014;37:E258–61.
12. Zahrina AZ, Haymond P, Rosanna P, Ho R, Rajini AR, Low BT, et al. Does the attire of a primary care physician affect patients'perceptions and their levels of trust in the doctor?. Malays Fam Physician 2018;13:3–11.
