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Medical Education
July 30, 2021

Has the Physician’s White Coat Seen Its Day?

Author Affiliations
  • 1Bozeman, Montana
  • 2Department of Surgery, University of Florida Health, Gainesville, Florida
JAMA Netw Open. 2021;4(7):e2119881. doi:10.1001/jamanetworkopen.2021.19881

Prior to the last part of the 19th century, physicians in the United States traditionally wore black attire, emphasizing the solemnity and formality of the doctoring profession. Attire changed rapidly as medicine became more scientifically grounded, particularly with the advent of antisepsis principles, resulting in a shift to white coats for physicians and white dresses for nurses.1 Throughout the 20th century, the physician’s white coat provided its wearers with a mantle of authority and trustworthiness; building on that tradition, in 1993 the Arnold P. Gold Foundation initiated the ritual of the White Coat Ceremony for entering medical students.2 White coat ceremonies have been widely adopted for those entering clinical professions and are now conducted for nursing, physician assistant, physical and occupational therapy, and pharmacy students.

Resistance to wearing the traditional white physician’s coat has mounted over the last 20 years. Although white coat hypertension—the phenomenon of patients having falsely elevated blood pressure when seen at a physician's office—is a widely touted phenomenon, the evidence for this physiologic derangement is poor at best. Slightly better data are available to implicate the white coat as a potential source of nosocomial infection, although no study has shown a definitive transmission from white coat to patient.3 Some see it as a symbol of power and hierarchy and have therefore questioned the relevance of the white coat in relation to the humanistic delivery of medical care.4 In pediatric and psychiatric practices, the white coat has generally been disposed of in the interest of patient psychological safety.

Xun et al5 offer new information that may further the dialogue regarding the role and relevance of the physician’s white coat. They effectively considered the relatively recent trend of institutional casual attire, specifically exploring layperson perceptions of physicians wearing either fleece or soft-shell jackets in place of the white coat. The broader acceptance of this attire by younger respondents from the Western United States provides a signal that if this sort of physician uniform were placed into more widespread use that it is likely to gain acceptance with increased familiarity. Perhaps the most challenging finding in their study was that professionally attired women in a white coat were viewed unfavorably in comparison with their male counterparts; the implicit bias that underlies this finding clearly requires more than a white coat for remediation. While one would hope that wearing a white coat would help patients and families to appropriately identify women physicians in their designated role, it seems probable that the expansion of white coats to almost all team members has diluted its value as a signal.

Previous assessments of attire and professionalism have reasonably asserted that tailored policies on physician attire should account for patient, health care professional, and context.6 The article by Xun et al5 reinforces the idea that physicians should dress in a manner that inspires the confidence of patients and that best supports physician job performance. Although public perceptions related to expertise may still favor white coats, perceptions of expertise also still widely favor older male physicians. It is therefore intriguing that for women physicians, no clear benefit to the patient-physician relationship can be attributed to wearing a white coat. In addition, this work still does not help us to unravel the relationship, if any, between patient biases and clinical outcomes. Perhaps the message embedded in the article by Xun et al5 is simply that the white coat’s importance is primarily symbolic and that it is no longer a prerequisite for physicians to provide high-quality and compassionate clinical care.

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Article Information

Published: July 30, 2021. doi:10.1001/jamanetworkopen.2021.19881

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Cochran A et al. JAMA Network Open.

Corresponding Author: Amalia Cochran, MD, 5535 Westmorland Dr, Bozeman, MT 59718 (amalia.cochran@aggienetwork.com).

Conflict of Interest Disclosures: None reported.

Disclaimer: Dr Cochran is web and social media editor of JAMA Surgery but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

References
1.
Hochberg  MS.  The doctor’s white coat—an historical perspective.   Virtual Mentor. 2007;9(4):310-314. doi:10.1001/virtualmentor.2007.9.4.mhst1-0704PubMedGoogle Scholar
2.
Arnold P. Gold Foundation. White Coat Ceremony. Published 2021. Accessed June 8, 2021. https://www.gold-foundation.org/programs/white-coat-ceremony/
3.
Bearman  G, Bryant  K, Leekha  S,  et al.  Healthcare personnel attire in non-operating-room settings.   Infect Control Hosp Epidemiol. 2014;35(2):107-121. doi:10.1086/675066PubMedGoogle ScholarCrossref
4.
Wear  D.  On white coats and professional development: the formal and the hidden curricula.   Ann Intern Med. 1998;129(9):734-737. doi:10.7326/0003-4819-129-9-199811010-00010PubMedGoogle ScholarCrossref
5.
Xun  H, Chen  J, Sun  AH, Jenny  HE, Liang  F, Steinberg  JP.  Public perceptions of physician attire and professionalism in the US.   JAMA Netw Open. 2021;4(7):e2117779. doi:10.1001/jamanetworkopen.2021.17779Google Scholar
6.
Petrilli  CM, Mack  M, Petrilli  JJ, Hickner  A, Saint  S, Chopra  V.  Understanding the role of physician attire on patient perceptions: a systematic review of the literature—Targeting Attire to Improve Likelihood of Rapport (TAILOR) investigators.   BMJ Open. 2015;5(1):e006578. doi:10.1136/bmjopen-2014-006578PubMedGoogle Scholar
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