Research

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EDUCATION

Does physician attire influence patient satisfaction in an

outpatient obstetrics and gynecology setting?
Richard L. Fischer, MD; Clare E. Hansen, RN; Robert L. Hunter, MD; J. Jon Veloski, MS
OBJECTIVE: The purpose of our study was to determine whether physician attire played a role in patient satisfaction after a new obstetrician/gynecologist encounter.
STUDY DESIGN: Over a 3-month period, 20 physicians were randomly

assigned to dress in business attire, casual clothing, or scrub suit each

week. One thousand one hundred sixteen patients who had an office
visit with a new obstetrician/gynecologist for at least 10 minutes completed a satisfaction survey, which assessed patient comfort as well as
perception of the competency and professionalism of the physician.
Patients were blinded to the physician attire manipulation.

RESULTS: There was no difference in the mean overall satisfaction

score among the 3 physician attire groups. No differences existed in
satisfaction scores when analyzed by individual survey item or by demographic factors, after controlling for attire.
CONCLUSION: Patients are equally satisfied with physicians who dress
in business attire, casual clothing, or scrub suit.

Key words: patient satisfaction, physician attire, physician-patient

relations

Cite this article as: Fischer RL, Hansen CE, Hunter RL, Veloski JJ. Does physician attire influence patient satisfaction in an outpatient obstetrics and
gynecology setting? Am J Obstet Gynecol 2007;196:186.e1-186.e5.

he physician-to-patient relationship has been characterized by a

delicate balance between compassion
and objectivity, leading to the description of the physician as the intimate
stranger.1 Nowhere is this term more
applicable than in the field of obstetrics
and gynecology, where the physician is
allowed to share in some of the most personal and memorable events in the life of
a woman. Paramount to a successful
physicianpatient interaction is the patients confidence in her physicians
competency and professionalism. The
role of physician attire in formulating
From the Department of Obstetrics and
Gynecology, University of Medicine and
Dentistry of New Jersey, Robert Wood
Johnson Medical School at Camden,
Cooper University Hospital, Camden, NJ
(Dr Fischer, Ms Hansen, and Dr Hunter),
and the Center for Research in Medical
Education and Health Care, Jefferson
Medical College, Philadelphia, PA (Mr
Veloski).
Received June 15, 2006; accepted Sep 26,
2006.
Reprints not available from the authors.
0002-9378/$32.00
2007 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2006.09.043

186.e1

these initial impressions has been widely

debated.2 The public image of appropriate physician attire has varied, depending on time, cultural expectations, and
generational preferences. Hippocrates
recommended that physicians should
dress decorous and simple, not overelaborated, but aiming rather at good repute, and adapted for contemplation, introspection and walking.3 Although
some physicians prefer the more traditional white coat attire to convey an air of
cleanliness, professionalism, and authority, others choose a more informal
attire in the hope of breaking down barriers, improving communications, and
creating a more equal physicianpatient
relationship.
Surveys on patient preferences for
physician attire have been conducted in
both the hospital and office settings, involving many different medical specialties. In most studies, patients expressed
preferences for specific physician items,
such as white coat and visible stethoscope, as well as shirt and tie for men,
and dress or skirt for women.4-9 However, few studies have focused exclusively
on patients in obstetrics and gynecology.
In 1 such study, Cha et al10 distributed a
questionnaire that asked patients in an
obstetrics and gynecology clinic about

American Journal of Obstetrics & Gynecology FEBRUARY 2007

their preferences for the attire of resident

physicians, and displayed pictures of
male and female residents in various
styles of dress. Though more than 60%
responded that physician attire did not
influence their perceptions, responses to
the pictures showed a significant trend
toward greater comfort and confidence
in the more formally attired physicians.
This investigation, as with the majority
of other attire studies, surveyed the patients idealized public image of a physician. Although this approach may assess
preconceived preferences of physician
appearance, it may not reflect the actual
patient satisfaction levels with physicians
in various attires.
The purpose of our study was to determine whether, in a new office encounter
with an obstetrician or gynecologist,
physician attire played a role in patient
comfort, as well as the perception of physician competency and professionalism.
We hypothesized that patient satisfaction would be unrelated to physician attire.

M ATERIALS AND M ETHODS

This observational trial was judged exempt by the Institutional Review Committee, as it was a patient satisfaction
survey. The study involved outpatients

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TABLE 1

Physician attire requirements

Attire

Dress requirements

Business

Men: Dress pants, button-down shirt, tie tightened up to collar, buttoned white
coat, shoes, no earrings

..............................................................................................................................................................................................................................................

Women: Dress, skirt and blouse, or pants suit, buttoned white coat, shoes, no
dangling earrings

..............................................................................................................................................................................................................................................

Casual

Men: Casual pants (eg, khaki or cotton, no jeans), polo shirt or button-down
shirt without tie, shoes (no clogs or sneakers), unbuttoned white coat
optional

..............................................................................................................................................................................................................................................

Women: Pants (eg, khaki or cotton, no jeans), polo shirt or collarless shirt,
shoes (no clogs or sneakers), unbuttoned white coat optional

..............................................................................................................................................................................................................................................

Scrubs

Hospital issue scrub top and bottom, shoes or sneakers or clogs, no white
coat (may use scrub jacket, fleece lined jacket, or colored collarless cotton
jacket)

seen by 20 full-time faculty members of

the department of obstetrics and gynecology at Cooper University Hospital in
Camden, NJ, from September through
November, 2005. Nine of the 20 physicians were from the general division of
obstetrics and gynecology, 6 from the division of maternal-fetal medicine, 3
from the division of female pelvic medicine and reconstructive surgery, and 2
from the division of gynecologic
oncology.
Over the 3-month period, physicians
were assigned to wear business attire, casual clothing, or scrub suit on a weekly
basis. The 3 modes of attire described in
Table 1 were clearly delineated, and conformed to the institutions dress code. A
buttoned white coat was required for
business attire, prohibited in scrub attire, and though discouraged, was permitted (unbuttoned only) for casual
dress. The schedule of attire for each
physician was determined by the principal investigator, who placed 3 different
colored sets of 4 identical-size plastic
disks, each color representing 1 of the
dress styles, into an opaque container.
He then sequentially selected without replacement each of the 12 disks and recorded the attire sequence for each
physician.
A copy of the randomized 12-week
schedule was sent to each physician. Subsequently, the physicians were reminded
each weekend by telephone and e-mail of
their assigned dress for the upcoming
week. If a physician was scheduled to be

away for a week during the study period,

the assigned attire sequence was maintained and the study was extended by 1
week for that individual so that every
physician dressed in each of the 3 attires
for a total of 4 weeks.
The front office staff at each of 12 outpatient sites maintained an attire log
sheet to monitor the physicians adherence to the clothing assignments at each
office session. The logs were faxed on a
weekly basis to the principal investigator,
who spoke with any physician who did
not dress according to the assigned
schedule.
Eligible patients for the study included
women with an office visit of at least 10
minutes with a new obstetrician or gynecologist, and no previous participation
in the study. Immediately after the physician encounter, the office staff asked eligible patients to participate in an anonymous survey. The 1-page questionnaire
asked for the patients age, ethnicity,
pregnancy status, and name of the physician. The patient was asked to confirm
that the office visit lasted at least 10 minutes, that it was her first time seeing the
physician, and that it was her first time
completing the questionnaire. The patient satisfaction rating scale included 10
affirmative statements about the physicians competence and professionalism,
the patients sense of comfort and confidence in her physician, and whether she
would return to or recommend the doctor to others (see Appendix). All statements were written at the 5th to 6th

Research

grade level as measured by the FleschKincaid readability scale. Responses

were marked on a 5-point Likert scale,
ranging from 1 (strongly disagree) to 5
(strongly agree). There were no questions about, or references to, the physicians clothing.
To assure patient anonymity, the date
of the physician visit was not recorded on
the questionnaire. As each physicians
attire was determined on a weekly basis,
the surveys were color-coded by week so
that the attire of each physician could be
determined from a master schedule after
study completion. At the conclusion of
the study, participating physicians were
also surveyed regarding their demographics and preferences for each of the 3
types of attire.
Statistical tests included 1-way analysis of variance (ANOVA) to compare
means among the 3 modes of attire, and
2-way ANOVA to test the effects of patient characteristics and their interaction
with attire. The 2 test was used to compare categorical variables. Cronbachs
alpha was calculated to estimate the internal consistency reliability of the questionnaire and product-moment correlations to estimate its validity. All
statistical analyses were performed with
either SPSS version 13.0 (SPSS Inc, Chicago, IL) or Stata (StataCorp LP, College
Station, TX). Statistical significance was
defined as a P value less than .05. Analysis
was based on intent-to-treat.

R ESULTS
A total of 1116 patients completed the
patient satisfaction survey over the
3-month period. No completed surveys
of eligible patients were excluded. The
demographics of the women and 20 participating physicians are shown in Table
2. The majority (64%) of respondents
were white, with an average age of 37
years. Forty-one percent were pregnant
at the time of their office visit. Among
participating physicians, the average age
was 42 years, with an equal number of
men and women. Compliance with the
assigned modes of attire was excellent.
Of 670 separate office sessions held by
the 20 physicians during the study period, there were only 11 instances of in-

FEBRUARY 2007 American Journal of Obstetrics & Gynecology

186.e2

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TABLE 2

Patient and physician demographics

Characteristic

Patients (n 1116)

Physicians (n 20)

Age (y)

37.3 15.6

41.9 1.7

..............................................................................................................................................................................................................................................

Ethnicity

.....................................................................................................................................................................................................................................

White

64%

65%

Black

.....................................................................................................................................................................................................................................

20%

20%

Hispanic

9%

0%

Asian

4%

10%

Other

3%

5%

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Pregnancy status

.....................................................................................................................................................................................................................................

Pregnant

41%

Nonpregnant

59%

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Physician gender

.....................................................................................................................................................................................................................................

Female

50%

Male

50%

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Results reported as percentage or mean SD of valid responses.

correct attire, for a compliance rate of

98.4%. No physicians dropped out of the
study.
Overall patient satisfaction was measured by the mean Likert scale score of the
first 8 affirmative statements of the survey,
with a value of 5 representing the highest
possible score. Among the 1116 respondents, patient satisfaction was very high,
with an overall mean score of 4.8 and a SD
of 0.4. The responses were analyzed to estimate the reliability and validity of the
scale. Internal consistency reliability was
extremely high, with a Cronbachs alpha of
0.97. The correlation between the mean response to the first 8 questions and responses to each of the last 2 questions,
which related to the patients willingness to
return to or recommend the physician,
was 0.87 for each.

Of the 1116 respondents, 375 were exposed to physicians in business attire,

373 to casual attire, and 368 to scrub suit
attire. Patient age and pregnancy rates
were similar among the 3 groups. There
was an unequal distribution of ethnicities, (0.008 by 2), with a greater percentage of Hispanic patients exposed to business attire and fewer white patients
exposed to scrub attire. There was no statistically significant difference in overall
satisfaction scores among the 3 groups
(Table 3). In addition, there were no significant differences among the 3 groups
with respect to any individual survey
question or when grouped by patient
comfort or perceived physician competency and professionalism.
An exploratory 2-way ANOVA was
performed to investigate any potential

TABLE 3

Patient satisfaction results

Variable

Business
(n 375)

Casual
(n 373)

Scrubs
(n 368)

P value*

Overall satisfaction score

4.8 0.3

4.8 0.4

4.8 0.4

.80

Would return to physician

4.9 0.4

4.8 0.4

4.8 0.5

.85

Would recommend
physician

4.8 0.4

4.8 0.5

4.9 0.5

.44

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

Data presented as the mean SD of valid responses.

* ANOVA, 1-way.

Overall satisfaction score was calculated as the mean of the first 8 survey questions.

186.e3

American Journal of Obstetrics & Gynecology FEBRUARY 2007

influence of demographics on satisfaction scores, either independently or interacting with mode of attire. The analysis revealed no significant effect of
patient age, physician gender, physician
specialty, or study week on patient satisfaction scores. Although there were significant differences in mean satisfaction
scores based on patient ethnicity, pregnancy status, physician, and outpatient
office site, the analysis showed no effect
of any of these factors on patient satisfaction scores in combination with different
types of physician attire.
Among the 20 participating physicians, 8 preferred casual dress, 7 preferred business attire, and 5 preferred to
wear scrub suits. There was no association between attire preference and physician age, race, gender, specialty, or
years in practice.

C OMMENT
Our study showed that women experiencing new encounters with obstetricians and gynecologists were equally satisfied with their physicians regardless of
their attire. When analyzed in conjunction with physician attire, there were no
differences in satisfaction for any subgroup of patient or physician characteristics.
These findings may at first glance seem
to contradict earlier published reports.1,4-10 In virtually all previous studies in which patients were asked specifically about physician attire, preferences
were expressed for items such as white
coats, ties, dress pants, and dresses.
However, these observations might be
biased because of perceived physician
stereotypes gleaned from television
medical shows and physician advertisements. We were interested in how
women, who were unaware that clothing
was being evaluated, would respond to
physicians in various attires. Therefore,
our surveys deliberately avoided asking
about physician attire.
The results of our study are consistent
with 4 others in which patient satisfaction surveys were administered after encounters with physicians in different attires. Pronchik et al11 randomized male
attendings, residents, and students in an

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emergency department to wear a necktie
or no necktie over a 6-week period. Patients completing a postencounter survey had similar ratings between the 2
groups with regard to medical care, interaction, and general physician appearance. In a study by Hennessy et al,12 a
single anesthesiologist visited inpatients
in either formal or casual attire. Patient
satisfaction with the anesthesiologists
professionalism and approachability was
not influenced by his attire. Ikusaka et
al13 surveyed 611 outpatients at an urban
Japanese hospital, with physicians wearing a white coat during the first week and
no white coat during the second week.
Overall satisfaction with the physician
consultation was equivalent in the 2
groups. Finally, Baevsky et al14 assigned
emergency medicine physicians and
physician assistants to wear either formal
(even days) or scrub suit attire (odd
days), both with white coats. As in our
study, patients were blinded to the nature of the trial, and physician attire was
not directly mentioned. Though the patient response rate was only 45% and the
physician noncompliance rate was approximately 20%, there was no difference in patient satisfaction by physician
attire when analyzed by either intent-totreat or by post-hoc analysis.
These 4 studies, along with our present
study, highlight the importance of study
design in assessing patient satisfaction.
When patients were asked their opinions
of physicians rather than apparel, physician approval scores did not differ by attire. Although patients may express a
predilection for specific items of clothing
or personal appearance, it is likely that
other factors, such as medical knowledge, personal demeanor, and interpersonal skills play a much more important
role in patient satisfaction.
Not only can the white coat and tie,
part of the traditional male physician attire, have little influence on patient satisfaction, but it can be potentially deleterious as well. White coat hypertension is
a long-recognized condition affecting
21% of individuals with borderline hypertension.15 Though it is unlikely that
this entity is due solely to the white coat,
more formal physician attire may lead to
a more intimidating atmosphere, patient

anxiety, and resulting hypertension. In

addition, studies have suggested that the
white coat and tie may harbor potentially
virulent bacterial organisms. Wong et
al16 cultured 100 physician white coats
from the sleeve cuff, front pocket, and
back. They found an average colony
count of 23.8 colony forming units from
the 300 samples taken, with the highest
colony counts originating from the cuff
and pockets. Although most of the isolates were skin flora, Staphylococcus aureus was isolated from 29% of white
coats. Similarly, in another study, neckties from 20 of 42 health care providers
harbored bacterial pathogens, compared
with only 1 of 10 neckties from nonhealth care hospital personnel.17
The greatest strength of our study
was the large sample size. With over
350 patients in each of the 3 groups,
our statistical power to detect a 10%
difference in overall satisfaction scores
was greater than 0.95 at an alpha of
0.05. Our study also encompassed a
mix of pregnant and nonpregnant
women from a wide variety of different
ages and ethnic groups. It should
therefore be generalizable to women in
various obstetrics and gynecology outpatient practices in our region. We
only included women having a new
physician encounter to avoid bias from
earlier interactions. Blinding of patients to the nature of the study was
ensured by not including any questions
about physician attire on the survey,
and by not having the physicians or office staff discuss attire with patients.
The participating physicians were remarkably compliant during the study
period, aided by the weekly reminders
from the investigators.
Our study had a number of limitations.
We used onsite handout evaluation forms
to ensure higher completion rates and for
cost containment. However, this may have
led to an artificially inflated satisfaction
score, as studies have shown that handout
surveys tend to score higher than mailed
surveys. Reasons include perceived lack of
anonymity, less time for thoughtful physician evaluation, and immediate postencounter optimism of the treatment
plans.18 Another limitation is that our results may not be generalizable outside of

Research

our geographic region, as patient attitudes

may vary in other areas of the country. Finally, the overwhelmingly positive patient
satisfaction responses may reflect a Hawthorne effect,19 in which physicians interpersonal conduct may have been improved because of their participation in
this research trial. In fact, our results are
similar to those in other comparably designed studies.11,14 The relative impact of a
Hawthorne effect is difficult to quantify, as
our institution did not distribute outpatient satisfaction surveys before this trial
for comparison with our current study results.
Although patient satisfaction may be
artificially elevated in this research setting, it does not diminish the important
finding that physicians, even those on
their best behavior, are seemingly valued
for their medical and interpersonal skills,
not their work attire. Given that medicine, like many other industries, is in
large part a consumer-driven business, it
underscores the importance of good
physician-patient interaction to maintain customer satisfaction and loyalty.
Our study results suggest that patient
satisfaction is not affected by a physicians decision to dress in business attire,
casual clothing, or scrub suit.
f
ACKNOWLEDGMENTS
The authors are indebted to all the participating
Cooper faculty physicians and office staff for
their cooperation during the study. We also
thank Autumn Gill and Kimberly McCaffrey from
Press Ganey Associates, Inc, for their assistance in constructing the patient satisfaction
survey.

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3. Bishop WJ. Notes on the history of medical
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4. Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract
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5. McKinstry B, Wang J. Putting on the style:
what patients think of the way their doctor
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10. Cha A, Hecht BR, Nelson K, Hopkins MP.
Resident physician attire: does it make a difference to our patients? Am J Obstet Gynecol
2004;190;1482-6.

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11. Pronchik DJ, Sexton JD, Melanson SW,
Patterson JW, Heller MB. Does wearing a necktie influence patient perceptions of emergency
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541-3.
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Patients attitude toward consultations by a
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Med 1999;38:533-6.
14. Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. The influence of physician attire on
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Harshfield GA, Blank S, Laragh JH. How com-

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16. Wong D, Nye K, Hollis P. Microbial flora
on doctors white coats. BMJ 1991;303:1602-4.
17. Nurkin S, Urban C, Mangini E, et al. Is the
clinicians necktie a potential fomite for hospital
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A PPENDIX
Please blacken the circle below that best describes your level of agreement with the following statements about the doctor that
treated you today:
Strongly disagree
I felt comfortable speaking with my doctor

My doctor listened to my concerns

My doctor spent adequate time with me

My doctor was knowledgeable

My doctor was competent

My doctor was professional

My doctor was friendly and courteous

I had confidence in my doctor

I would return to this doctor in the future

I would recommend this doctor to others

Disagree

No opinion

Agree

Strongly agree

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American Journal of Obstetrics & Gynecology FEBRUARY 2007