Bare below the elbows: A cheap soundbite

The importance of the orthopaedic doctors' appearance: a cross-regional questionnaire based study

OBJECTIVES

Critics of the Department of Health 'bare below the elbow' guidelines have raised concerns over the impact of these dress regulations on the portrayed image and professionalism of doctors. However, the importance of the doctor's appearance in relation to other professional attributes is largely unknown. The purpose of this study was to determine the opinion of patients on the importance of appearance and the style of clothing worn by doctors.

DESIGN

Patient questionnaire survey, administered across four Scottish regions.

SETTING

Orthopaedic outpatient departments.

PARTICIPANTS

427 patients and accompanying relatives.

MAIN OUTCOME MEASURES

The absolute and relative importance of the doctors' appearance, as reported using a 5-point Likert scale. The absolute and relative importance of the style of clothing worn by doctors, as reported using a 5-point Likert scale. The rank preferences for four different styles of doctors' attire as illustrated by standardised clinical photographs.

RESULTS

The study was appropriately powered to identify a 0.5 difference in mean rank values with 0.90 power at a = 0.05. The majority of participants felt the doctors' appearance was important but not as important as compassion, politeness and knowledge. Only 50% felt that the style of doctors clothing mattered; what proved more important was an impression of cleanliness and good personal hygiene. In terms of how patients would prefer doctors to dress in clinic, the most popular choice proved to be the smart casual style of dress, which conforms with the 'bare below the elbows' dress code policy. The smart casual clothing style was the highest ranked choice irrespective of patient age, gender, regional or socioeconomic background.

CONCLUSIONS

The doctors' appearance is of importance to patients and their relatives, but they view many other attributes as more important than how we choose to dress. While not specifically addressing the role of doctors clothing in the transmission of infection, our results do support the preference of patients for 'bare below the elbows' workplace attire.

Patients' perceptions of doctors' clothing: should we really be 'bare below the elbow'?

INTRODUCTION

In September 2007, the Department of Health published Uniforms and Workwear: an Evidence Base for Guiding Local Policy. Following this, most National Health Service trusts imposed a 'bare below the elbow' dress code policy, with clinical staff asked to remove ties, wristwatches and hand jewellery and to wear short-sleeved tops. There is currently no evidence linking dress code to the transmission of hospital-acquired infection. We designed the current survey to assess patients' perceptions of doctors' appearance, with specific reference to the 'bare below the elbow' policy.

MATERIALS AND METHODS

A questionnaire showing photographs of a doctor in three different types of attire ('scrubs', formal attire and 'bare below the elbow') were used to gather responses from 80 in-patients and 80 out-patients in the ENT department. Patients were asked which outfit they felt was the most hygienic, the most professional and the easiest identification of the person as a doctor. They were also asked to indicate their overall preference.

RESULTS AND ANALYSIS

Formal attire was considered most professional and the easiest identification that the person was a doctor. Scrubs were considered most hygienic. Respondents' overall preference was divided between scrubs and formal clothes. 'Bare below the elbow' attire received the lowest votes in all categories.

DISCUSSION

This finding raises significant questions about the Department of Health policy in question. The authors suggest that an alternative policy should be considered, with scrubs worn for in-patient situations and formal attire during out-patient encounters.

Effects of 'bare below the elbows' policy on hand contamination of 92 hospital doctors in a district general hospital

Despite a lack of evidence the UK's Department of Health introduced a policy of 'bare below the elbows' attire in order to try to reduce the incidence of nosocomial infection. This study investigates the link between this state of dress and hand contamination. A prospective observational study of doctors working in a district general hospital was carried out. The fingertips of each hand were imprinted onto culture medium, and resultant growth assessed for number of colony-forming units and presence of clinically significant pathogens or multiply resistant organisms. These findings were correlated with attire, grade, sex and specialty. Ninety-two doctors were recruited of whom 49 were 'bare below the elbows' compliant and 43 were not. There was no statistically significant difference between those doctors who were 'bare below the elbows' and those that were not, either for the number of colony-forming units or for the presence of clinically significant organisms. No multiply resistant organisms were cultured from doctors' hands. 'Bare below the elbows' attire is not related to the degree of contamination on doctors' fingertips or the presence of clinically significant pathogens. Further studies are required to establish whether investment in doctors' uniforms and patient education campaigns are worthwhile.