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Original Investigation |

Patient Preference in Dermatologist Attire in the Medical, Surgical, and Wound Care Settings

Joshua D. Fox, MD1; Giselle Prado, BS2; Katherine L. Baquerizo Nole, MD1; Flor Macquahe, MD1; Ingrid Herskovitz, MD1; Ashley Rosa, MD1; Shifa Akhtar, BS3; Adam Aldahan, BS1; Vidhi Shah, BS1; Stephanie Mlacker, BS1; Gabriel Cardenas, MPH4; Robert S. Kirsner, MD, PhD1
[+] Author Affiliations
1Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
2Herbert Wertheim College of Medicine, Florida International University, Miami
3University of Miami, Miami, Florida
4Division of Biostatistics, Department of Health Services and Research, University of Miami Miller School of Medicine, Miami, Florida
JAMA Dermatol. 2016;152(8):913-919. doi:10.1001/jamadermatol.2016.1186.
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Importance  Patients’ perceptions of their physician can affect subjective and objective outcomes. Physician attire influences patients’ perceptions of their physician and consequently may affect patient outcomes.

Objective  To determine patient preferences for different types of dermatologist attire in dermatology medical, surgical, and wound care clinics. We hypothesized that patients in the dermatology medical setting would prefer professional attire, while patients in the dermatology surgical and wound care setting would prefer surgical scrubs.

Design, Setting, and Participants  This study analyzed responses to a cross-sectional, anonymous survey by English-speaking dermatology patients (aged 18 years or older) at general, surgical, and wound care clinics in an academic center in Miami, Florida. Patients who could not read and understand the survey were excluded. Participants received pictures of a physician wearing business attire, professional attire, surgical attire, and casual attire, and responded by indicating which physician they preferred for each of 19 questions. Frequencies of responses were recorded, and χ2 and regression tests were performed.

Main Outcomes and Measures  Response frequencies.

Results  Surveys were administered to 261 persons, and 255 participated and completed enough of the questions to be included in the outcome analyses (118 men, 121 women, 22 unknown [did not answer sex question]), mean (SD) age, 56.3 (18.6) years; about 49% of those who reported their sex were men; 56% were Hispanic; and 85% were white. Approximately 72% of respondents held a college degree or higher. About 63%, 24%, and 13% of respondents were medical, surgical, and wound care dermatology patients, respectively. Roughly 73%, 19%, 6%, and 2% of cumulative responses were for professional, surgical, business, and casual attire, respectively. Respondents who received a picture of a black male or black female physician were more likely to exclusively prefer professional attire: unadjusted odds ratios (ORs) 3.21 (95% CI, 1.39-7.42) and 2.78 (95% CI, 1.18-6.51), respectively, compared with respondents who received a picture of a white male physician. Nonwhite and unemployed respondents were less likely to prefer professional attire exclusively: ORs, 0.28 (95% CI, 0.1-0.83) and 0.28 (95% CI, 0.08-0.99), respectively. Respondents preferred professional attire in all clinic settings, though respondents in the dermatology surgery clinic were less likely to prefer professional attire compared with respondents in the medical dermatology clinic: race-adjusted OR, 0.74 (95% CI, 0.56-0.98). Wound care and medical dermatology respondents preferred professional attire comparably.

Conclusions and Relevance  In this study, most patients preferred professional attire for their dermatologists in most settings. It is possible that patients’ perceptions of their physicians’ knowledge and skill is influenced by the physicians’ appearance, and these perceptions may affect outcomes.

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Attire Survey Images

Each respondent received a single picture series, 1, 2, 3, or 4, in his or her survey. The picture series were cycled through consecutively, so the respondent essentially received his or her picture series at random. Images reprinted with permission, courtesy of Elsevier Publishing (Am J Med. 2005;118:1279-1286; doi:10.1016/j.amjmed.2005.04.026); copyright 2005 Elsevier Inc.

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Submit a Comment
A missed opportunity to discuss racial and gender bias in dermatology
Posted on June 13, 2016
Adewole S. Adamson, MD, MPP, Sylvia W. Wright, MD, Amit G. Pandya, MD
UNC Chapel Hill Department of Dermatology; Peachtree Dermatology Associates; UTSW Department of Dermatology
Conflict of Interest: None Declared
Race and gender are often overlooked in clinical interactions despite affecting the physician-patient relationship. Regretfully, JAMA Dermatology missed an opportunity to have a candid discussion about race and gender bias in the practice of dermatology.

In an original investigation published in the June issue of JAMA Dermatology, researchers aimed to determine whether attire influenced patients’ perception of physician competence, trust, compassion, communication and knowledge.1 A cohort of predominantly white Hispanic outpatient clinic patients in a Miami academic center received pictures of a physician wearing business attire, professional attire, surgical attire, and casual attire along with a survey of preference of physician for a series of questions. Patients received pictures of one of four physicians: an African-American male physician, white male physician, African-American female physician or white female physician.

Investigators found that respondents considerably preferred African-American and women physicians to wear professional attire. Patients were twice as likely to prefer white women and three times as likely to prefer African-American physicians in professional attire as compared to white men. In fact, of all the respondent characteristics captured in this study, race/gender were the greatest predictors of preferring professional attire. This finding is the textbook definition of gender and racial bias. The exact same images were shown to patients in a Veterans Affairs internal medicine outpatient clinic which showed gender bias but no racial bias, possibly due to the fact that 38% of the respondents were Black. 2

This study may have uncovered racial and gender bias because respondent choice was constrained. Respondents were not given the choice of selecting “indifferent to attire” but were forced to decide between four dress styles. In a systematic review regarding patients’ perceptions of physician attire, 6 out of 10 U.S. based studies showed that attire did not influence patients’ perception of physicians.3 It is possible that most respondents in the study by Fox et. al had no preference.1 However, when given the constraint of dress code, physician race, and physician gender, the largely white respondents strongly preferred women and African-American physicians to dress professionally. Given this constraint, the results imply that white male physicians display competence, command authority, engender trust and appear knowledgeable to their patients regardless of attire.

The racial and gender bias uncovered in this study is perhaps the most important aspect of this study and should have been discussed further, with suggestions for future efforts to reduce this bias. Ideally, a patient’s trust and confidence in a physician should be based on knowledge, clinical skill, compassion and professionalism, not race or gender. Perhaps a way to combat this bias it to develop a more diverse workforce in dermatology.4-6 However, this cannot happen if racial and gender biases are not acknowledged by name when encountered, particularly in controlled research settings. If, as Fox et al argues, “patients’ perceptions of their physicians’ knowledge and skill are influenced by the physicians’ appearance,” then it should also be recognize that these perceptions are influenced by the doctor’s race and gender as well.

References

1. Fox JD, Prado G, Baquerizo Nole KL, et al. Patient Preference in Dermatologist Attire in the Medical, Surgical, and Wound Care Settings. JAMA Dermatol. 2016.
2. 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(11):1279-1286.
3. 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.
4. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587.
5. Imadojemu S, James WD. Increasing African American Representation in Dermatology. JAMA Dermatol. 2016;152(1):15-16.
6. Cheng MY, Sukhov A, Sultani H, Kim K, Maverakis E. Trends in National Institutes of Health Funding of Principal Investigators in Dermatology Research by Academic Degree and Sex. JAMA Dermatol. 2016.
Editor's Note
Posted on June 24, 2016
Dr. Ashish Bhatia
Web Editor for JAMA Dermatology
Conflict of Interest: None Declared
Journals do not have manuscripts discuss things that were not part of the research performed. By posting this comment, we open the topic for discussion on our site.
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