Figure. Family selection of the best physician to care for a family member admitted to the intensive care unit from photograph panels of physicians in 4 different dress styles. Data are presented as point estimates with 95% confidence intervals.
Au S, Khandwala F, Stelfox HT. Physician attire in the intensive care unit and patient family perceptions of physician professional characteristics. JAMA Intern Med. Published online February 18, 2013. doi:10.1001/jamainternmed.2013.2732
eAppendix. Survey instrument
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Au S, Khandwala F, Stelfox HT. Physician Attire in the Intensive Care Unit and Patient Family Perceptions of Physician Professional Characteristics. JAMA Intern Med. 2013;173(6):465–467. doi:10.1001/jamainternmed.2013.2732
Author Affiliations: Department of Critical Care Medicine (Drs Au and Stelfox) and Departments of Medicine & Community Health Sciences and Institute for Public Health (Dr Stelfox), University of Calgary, and Alberta Health Services–Calgary Zone (Drs Au and Stelfox and Ms Khandwala), Calgary, Alberta, Canada.
Physician attire is a modifiable factor that has been demonstrated to influence the patient-physician relationship.1-6 However, patient-physician interactions in the intensive care unit (ICU) differ from other health care settings. Patients admitted to the ICU typically do not have a preexisting long-term relationship with their ICU physician, and therefore trust needs to be established over a short time frame.7 The severity of patient illness frequently results in the active participation of family as surrogate decision makers, complicating the patient-physician relationship. The high acuity of the ICU makes for a wide range of attires worn, from scrubs to suits. We therefore conducted a survey in 3 ICUs to examine ICU patient family perceptions and preferences for physician attire.
We performed a cross-sectional survey of family members of consecutive patients admitted to 3 medical-surgical ICUs (Calgary, Alberta, Canada) during the period November 1, 2010, to October 31, 2011, to assess self-expressed preference for physician attire. Participants were asked to rate the importance of 10 physician-related factors (age, sex, race, neat grooming, facial piercings, visible tattoos, professional dress, white coat, visible name tag, and overall first impression) using a 5-point Likert scale and to select the best physician from photograph panels of 4 physicians (eAppendix). Photograph panels were generated from a stratified random of 32 photographs of 8 physician models to ensure that each panel contained a photograph of each study attire (traditional white coat, scrubs, suit, and casual attire), 2 male and 2 female models, and 1 model of each visible race (white, black, Indian, and Asian). Binomial confidence intervals were computed for observed categorical responses and compared using χ2 tests. All analyses were performed with SAS version 9.2 (SAS Institute Inc) statistical software. The study was approved by the Conjoint Health Research Ethics Board.
The survey was offered to 501 family members, and 337 (67%) agreed to participate. Participants were predominantly female (68%); white (78%); college or university educated (60%); and immediate family members (79%) of primarily male (59%), severely ill (mean APACHE II [Acute Physiology And Chronic Health Evaluation II] score of 24) patients admitted because of respiratory failure (31%). The patient characteristics of family members who responded to the survey were similar to those who did not. The median time from patient ICU admission to family members being offered the survey was 3 days (interquartile range, 1-5 days).
A majority of participants reported that wearing an easy to read name tag (77%), neat grooming (65%), and professional dress (59%) were important when first meeting a family member's ICU physician, while a minority felt that physician sex (3%), race (3%), age (10%), absence of visible tattoos (30%) and piercings (39%), or wearing a white coat (32%) were important.
Conversely, when selecting their preferred physician from a panel of pictures, respondents strongly favored physicians' wearing traditional attire with the white coat (Figure). Physicians in traditional dress were seen as most knowledgeable and most honest. Physicians wearing either scrubs or a white coat were seen as most competent to perform a life-saving procedure and most caring. When participants were asked to select the best physician overall, they selected physicians wearing traditional attire with a white coat (52%), followed byscrubs (24%), suit (13%), and casual attire (11%) (P < .001 for test of proportions). Survey responses were similar across participant age, sex, race, relationship to patient, and education.
In our study, a majority of respondents indicated that it was important for physicians to be neatly groomed, be professionally dressed, and wear visible name tags, but not necessarily a white coat. Despite these self-reported preferences, when patients' families selected their preferred physician from a panel of photographs, respondents strongly favored physicians wearing traditional attire with the white coat. Traditional attire was associated with perceptions of knowledge, honesty, and providing best overall care. Physicians wearing scrubs were a second choice among participants and were perceived to be caring and competent to perform a lifesaving procedure.
Our study provides the first description of ICU patient family perceptions and preferences of physician attire. Our results highlight 3 key observations. First, in contradiction to the theory that patients have less preference for traditional attire in the acute care setting,8 we observed a family preference for physicians wearing white coats or scrubs. Second, the 2 most preferred attires in our study, white coat and scrubs, share the commonality of being a uniform, which may help patients and families identify their health care providers. Third, we affirmed that regardless of dress, professionalism, neat grooming, and a clear name tag are perceived as a requisite by patient families. These results suggest that while families may not express preferences for how physicians dress, there may be subconscious associations with well-recognized physician uniforms including white coats and scrubs. Given the importance of effective communication in the ICU, physicians may want to consider that their attire could influence family rapport, trust, and confidence.
Correspondence: Dr Stelfox, Teaching Research & Wellness Building, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada (email@example.com).
Published Online: February 18, 2013. doi:10.1001/jamainternmed.2013.2732
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Au, Khandwala, and Stelfox. Acquisition of data: Au. Analysis and interpretation of data: Au, Khandwala, and Stelfox. Drafting of the manuscript: Au, Khandwala, and Stelfox. Critical revision of the manuscript for important intellectual content: Au and Stelfox. Statistical analysis: Khandwala. Obtained funding: Stelfox. Administrative, technical, and material support: Stelfox. Study supervision: Stelfox.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project was supported by an establishment grant from Alberta Innovates. Dr Stelfox is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates.
Role of the Sponsors: The funding sources had no role in the design, conduct, or reporting of this study.
Previous Presentation: This study was presented at the 41st Critical Care Congress; February 4, 2012; Houston, Texas.
Additional Contributions: We thank Barbara Artiuch, MD, and Jessalyn Holidinsky, BSc, for their help with administering the survey instrument and Matthew James, MD, PhD, for his comments on earlier versions of the manuscript.