Patients’ initial impressions of their physicians lay the foundation for subsequent physician–patient interactions and influence patients’ confidence in their physicians. In all medical disciplines, patients are typically seeking a physician who, in addition to having the appropriate medical expertise, demonstrates professionalism and clinical competence.
In the field of pediatric ophthalmology, parental anxiety can be magnified by concern about their child’s vision. Because parents may have difficulty gauging the clinical or surgical competence of their physician, they tend to rely on subjective parameters such as physician rapport, making patient and parent satisfaction during initial consultation an important goal.
A paucity of objective evidence exists to guide physician etiquette in the field of pediatric ophthalmology. We report and offer our analysis of the expressed preferences of families visiting a pediatric ophthalmology for the first time.
Patients and Methods
Parents or guardians of children visiting our pediatric ophthalmology clinic for the first time between June 1 and September 30, 2008, were asked to complete an open- and closed-ended questionnaire regarding their preferences on physician attire, salutations, and gender. Demographic information collected included age, gender, race/ethnicity, and education level of the parent or guardian completing the survey, as well as the age and gender of the child to be examined. Parents were asked specifically how they would like their physician to dress and introduce himself or herself and whether they would like their physician to wear a white coat. Parents were also asked how they would like their physician to greet and address both the parents and children. The survey was available to parents in both English and Spanish. Participants were asked to complete surveys in their entirety; any surveys not completed properly were excluded from analysis. The Fisher exact and chi-squared tests were used to compare subpopulations; a P value of less than .05 was necessary to achieve significance. This study was approved by an institutional review board.
A total of 201 surveys were distributed to families of pediatric patients prior to meeting their physician; 52 surveys were incomplete and therefore excluded from analysis. The remaining 149 surveys were included in our analysis. Female guardians completed 84.7% of the surveys and 45.3% of the children examined were female. The average age of pediatric patients examined was 4.5 years (range: 0.1 to 17 years; median: 3.0 years). The average age of the parent/guardian completing the survey was 34.9 years (range: 18 to 76 years; median: 33.5 years).
Of the respondents, 75.8% felt that the way they were greeted by their physician affected their trust and confidence in him or her. The majority of parents (91.9%) expressed no preference with regard to the gender of their physician, but 7.4% preferred a female physician and 0.7% (a single patient) preferred a male physician. Of the 11 parents who preferred their child be examined by a female physician, 10 (91.0%) were female.
Our findings, including the ethnic and educational demographics of our population, are summarized in the table. Informal greetings such as “mom” and “dad” were popular among the surveyed population. Only 40.9% of respondents reported that the way their physician dressed affected their trust and confidence in him or her. Although 67.8% of respondents had no preference with regard to the attire of their male physician, 22.1% preferred their male physician to dress in business casual attire. No preference with regard to the attire of their female physicians was indicated by 65.5% of respondents and 22.3% preferred their female physician to dress in business casual attire. A total of 57.7% of respondents preferred that their physician wear a white coat while examining their child. Four survey respondents (2.7%) expressed a preference for male physicians to wear scrubs; 8 survey respondents (5.4%) expressed a preference for female physicians to wear scrubs.
Statistical analysis revealed that men were more likely than women to prefer a handshake to a verbal greeting for their children (P = .0264) and professional attire (ie, dark suit with tie) to business casual attire for both male and female physicians (P = .01, both). No statistically significant differences were found comparing the preferences of parents with an advanced education (bachelor and graduate degrees) to those without. African-American parents were more likely to prefer being addressed by surname than other races (P = .008).
The idea that the physician–patient relationship is influenced by verbal and nonverbal communication at the time of the initial consultation dates back to the time of Hippocrates, who stated that physicians ought to be “clean in person, well dressed, and anointed with sweet-smelling unguents.”1 Contemporary research has shown that physician attire and demeanor continues to be an important consideration in a patient’s ability to trust a physician.2 In general, review of the literature suggests that professional and semi-professional attire inspires greater physician trust and confidence among adult patients.3–8 Children also appear to prefer formal attire, but not to the same degree as their parents.9
Rehman et al. surveyed 400 adult subjects in a South Carolina internal medicine clinic and found that respondents overwhelmingly favored professional attire with a white coat (76.3%; P < .0001) to surgical scrubs (10.2%), business dress (8.8%), and casual dress (4.7%).8 Respondents’ trust and confidence were significantly associated with their preference for professional dress (P < .0001), and they were significantly more willing to share their social, sexual, and psychological problems with a professionally dressed physician (P < .001).
Lill et al.10 conducted a survey of approximately 450 inpatients and outpatients with regard to physician dress, demeanor, and salutation. Patients expressed a preference for a physician photographed in semi-formal attire, especially when the physician was smiling. Patients were more comfortable with conservative items of clothing, such as long sleeves, covered shoes, and dress trousers than with less conservative items such as facial hair, short tops, and earrings on men, although certain items such as jeans were still acceptable to most.10 Most patients preferred to be called by their first name and to be introduced to their physician by full name and title.
However, some studies have found the impact of physician attire on patient trust may be marginal: two studies involving dress styles being alternated in physicians to compare measurement of patient satisfaction found that dress did not correlate with estimates of a clinician’s courteousness, concern, or professionalism.11,12
The wearing of white coats has recently come under scrutiny,13,14 and review of the medical literature yields conflicting opinions on the subject. White coats are traditionally worn to communicate a level of professionalism,15 but some have argued that they should be abandoned in patient-centered practices because they make the wearer appear more authoritative and less compassionate. It has been suggested that their effect is strong enough to cause significant physiologic changes in adults (ie, “white coat hypertension”) and induce anxiety in children, although this is debatable.16 Despite reports to the contrary in professional journals and in the popular press,15,17–19 patients have stated that physicians wearing white coats appear more “hygienic” and that the uniform enhances communication.20–22 Only 1% of patients in a recent study believed that white coats spread infection.20 In our study, most adults accompanying children to an office visit preferred that their physician wear a white coat.
The majority of our survey respondents expressed no preference with regard to the gender of their physician, but of the 11 parents who preferred their child be examined by a female physician, 10 were female. Previous studies have also documented female patient preference for female physicians.23 Parents were also slightly more particular about female physician wardrobe than that of males. Rehman et al.8 also found that patients tend to place greater importance on female physician attire than that of males. They theorized that because men have traditionally been more likely than women to become physicians, patients may feel that women physicians need to make an extra effort to appear professional so that they are not confused with other professional groups (such as nurses, dieticians, and social workers) that have historically had a female predominance.
Makoul et al.24 performed a large study of greetings in medical encounters in which 415 adults in 48 states were surveyed regarding preferences on shaking hands, use of patient names, and use of physician names. Most (78.1%) of the 415 survey respondents preferred physicians to greet them by handshake. The majority of patients preferred that physicians introduce themselves by their first and last name (56.4%) and be greeted by their first name only (50.4%). Other studies have also documented patient preference for address by first name only.25 The preponderance of the literature and our survey results suggest that physicians should introduce themselves by last name and offer a handshake to most pediatric patients and their families, taking care, of course, to maintain hygienic practices with alcohol gels or hand washing.
In general, our survey respondents preferred to be addressed informally (eg, as “mom” or by first name) and preferred that children be addressed by first name only. It should be noted that addressing patients/parents as familiars (ie. Joe) but referring to oneself by title and surname (ie, Dr. Smith) can suggest a sense of imbalance or medical paternalism that may not be ideal in all situations, and so although this appears to be the general preference of most survey respondents, it is probably best to proceed on a case-by-case basis.
A larger sample size would have increased the power of our findings. We must also acknowledge that our findings may reflect regional and/or cultural preferences because surveys were distributed among patients visiting a tertiary care center in Houston, Texas. Because our study was performed at a tertiary care center, caution should be used in generalizing the results to other practice situations.
Based on our results, pediatric ophthalmologists may wish to consider wearing white coats and business casual attire in clinic, greeting parents and children with a handshake (especially if the parent accompanying the child is male), and addressing parents informally as “mom” or “dad” or by their first name. Cultural differences may influence patient expectations. Each patient is different—physicians should be attuned to the nonverbal and verbal communication methods within their patient community. The concordance of our findings with those of Makoul et al.24 and others suggests that the population surveyed in this series is representative of the nation as a whole; however, further study to assess the generalizability of our findings is recommended. Future research could involve larger patient numbers and multicenter cross-sectional survey methodology at regular intervals to detect any regional, cultural, and gender differences in patient preferences and to document changes in patient preferences over time.
- Hippocrates. 1923 Hippocrates. In: Jones WHS, ed. Hippocrates, Selected Works Loeb Series. Cambridge, MA: Harvard University Press; 1923:311–312.
- McNaughton-Filion, L, Chen, JS & Norton, PG. The physician’s appearance. Fam Med. 1991;23:208–211.
- Blumhagen, DW. The doctor’s white coat: the image of the physician in modern America. Ann Intern Med. 1979;91:111–116.
- Hedberg, SE. Clothes and confidence. N Engl J Med. 1969;280:620. doi:10.1056/NEJM196903132801121 [CrossRef]
- Kriss, JP. Sounding board: on white coats and other matters. N Engl J Med. 1975;292:1024–1025. doi:10.1056/NEJM197505082921910 [CrossRef]
- Lynch, PI. Letter: the physician’s clothes. N Engl J Med. 1975; 293:1270.
- Mayberry, WE. The elements of style in medicine. Mayo Clin Proc. 1986;61:666–668.
- Rehman, SU, Nietert, PJ, Cope, DW & Kilpatrick, AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118:1279–1286. doi:10.1016/j.amjmed.2005.04.026 [CrossRef]
- Marino, RV, Rosenfeld, W, Narula, P & Karakurum, M. Impact of pediatricians’ attire on children and parents. J Dev Behav Pediatr. 1991;12:98–101. doi:10.1097/00004703-199104000-00005 [CrossRef]
- Lill, MM & Wilkinson, TJ. Judging a book by its cover: descriptive survey of patients’ preferences for doctors’ appearance and mode of address. BMJ. 2005;331:1524–1527. doi:10.1136/bmj.331.7531.1524 [CrossRef]
- Baevsky, RH, Fisher, AL, Smithline, HA & Salzberg, MR. The influence of physician attire on patient satisfaction. Acad Emerg Med. 1998;5:82–84. doi:10.1111/j.1553-2712.1998.tb02583.x [CrossRef]
- Hennessy, N, Harrison, DA & Aitkenhead, AR. The effect of the anaesthetist’s attire on patient attitudes: the influence of dress on patient perception of the anaesthetist’s prestige. Anaesthesia. 1993;48:219–222. doi:10.1111/j.1365-2044.1993.tb06905.x [CrossRef]
- Parker-Pope, T. Do you really want to see your doctor’s elbows?The New York Times. September8, 2008. Available at: http://well.blogs.nytimes.com/2008/09/08.
- Jones, A. Bare below the elbows: a brief history of surgeon attire and infection. BJU Int. 2008;102:665–666. doi:10.1111/j.1464-410X.2008.07713.x [CrossRef]
- Wong, D, Nye, K & Hollis, P. Microbial flora on doctors’ white coats. BMJ. 1991;303:1602–1604. doi:10.1136/bmj.303.6817.1602 [CrossRef]
- Matsui, D, Cho, M & Rieder, MJ. Physicians’ attire as perceived by young children and their parents: the myth of the white coat syndrome. Pediatr Emerg Care. 1998;14:198–201. doi:10.1097/00006565-199806000-00006 [CrossRef]
- Babb, JR, Davies, JG & Ayliffe, GA. Contamination of protective clothing and nurses’ uniforms in an isolation ward. J Hosp Infect. 1983;4:149–157. doi:10.1016/0195-6701(83)90044-0 [CrossRef]
- Barrett, TG & Booth, IW. Sartorial eloquence: does it exist in the paediatrician-patient relationship?BMJ. 1994;309:1710–1712. doi:10.1136/bmj.309.6970.1710 [CrossRef]
- Grys, E & Pawlaczyk, M. Does a physician’s apron protect against nosocomial infection? [article in Polish]. Ginekol Pol. 1996;67:309–312.
- Douse, J, Derrett-Smith, E, Dheda, K & Dilworth, JP. Should doctors wear white coats?Postgrad Med J. 2004;80:284–286. doi:10.1136/pgmj.2003.017483 [CrossRef]
- Gooden, BR, Smith, MJ, Tattersall, SJ & Stockler, MR. Hospitalised patients’ views on doctors and white coats. Med J Aust. 2001;175:219–222.
- Menahem, S & Shvartzman, P. Is our appearance important to our patients?Fam Pract. 1998;15:391–397. doi:10.1093/fampra/15.5.391 [CrossRef]
- Neinstein, LS, Stewart, D & Gordon, N. Effect of physician dress style on patient-physician relationship. J Adolesc Health Care. 1985;6:456–459. doi:10.1016/S0197-0070(85)80053-X [CrossRef]
- Makoul, G, Zick, A & Green, M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med. 2007;167:1172–1176. doi:10.1001/archinte.167.11.1172 [CrossRef]
- Gillette, RD, Filak, A & Thorne, C. First name or last name: which do patients prefer?J Am Board Fam Pract. 1992;5:517–522.
Survey Responses for Physician Etiquette in Pediatric Ophthalmology
|No. of female children||82||55|
|No. of male children||67||45|
|Parent/guardian education level|
| Did not graduate from high school||10||6.7|
| High school graduate/GED||20||13.4|
| Some college||49||32.9|
| College graduate||43||28.9|
| Any postgraduate study||27||18.1|
|Parental greeting preferencesa|
| No preference||5||3.4|
|Parental address preferencesa|
| First name||55||36.9|
| Last name||31||20.8|
| First and last name||1||0.7|
| No preference||5||3.4|
|Child greeting preferencesa|
| No preference||4||2.7|
|Child address preferencesa|
| First name||145||97.3|
| Last name||2||1.3|
| First and last name||1||0.7|
| No preference||2||1.3|
|Physician introduction preferencesa|
| First name||17||11.4|
| Last name||81||54.4|
| First and last name||50||33.46|
| No preference||3||2|
| Latin American or Hispanic||49||32.9|
| African American or Black||23||15.4|
| Asian or Pacific Islander||7||4.7|
| No high school diploma||10||6.7|
| High school diploma||20||13.4|
| Some college education||49||32.9|
| Bachelor’s degree||43||28.9|
| Postgraduate education||27||18.1|
A 2-year-old girl is accompanied by her mother to a pediatric ophthalmologist’s office for evaluation of a possible lazy eye.
Based on the data in this article, what do most caregivers prefer that a pediatric ophthalmologist wear when seeing their patients in clinic?
Business casual attire.
Most of the survey respondents preferred the following type of greeting by their pediatric ophthalmologist:
A high five.
A verbal greeting only.
Based on the survey data, the preferred method of addressing the patient’s mother in this type of scenario is:
By the mother’s last name.
By the patient’s first name.
By addressing the mother as “Mom.”
By addressing the child only.
Based on the survey data, the preferred way that a pediatric ophthalmologist should introduce himself or herself is:
By first name only.
By last name only.
By first and last name.
By “Doctor” only.