Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene

Having recently moved to Switzerland after training and working in different NHS hospitals in England and Scotland, I am puzzled by the abandonment of doctors' white coats in the UK. In Zurich, all doctors are issued with white vests, trousers and coats - exchangeable for laundered items whenever needed. Coats provide pockets for instruments, books, reference tables; adjustment to ambient temperature; an easy way for patients and fellow staff to recognise doctors by name and position; a sense of "corporate identiy" among clinicians; and a quick way of changing into clean clothes. Sleeve-free vests that guarantee bare-below-the-elbow during direct patient contact are worn underneath. Infection spread is minimised by encouraging staff to frequently change clothes. Surely, this approach is more suitable than entering and leaving the ward in the same shirt or blouse worn at home, in public transport and so on? The threshold for washing, drying and ironing one's clothes after a busy day in the clinic may be particularly high for young doctors who furthermore often struggle to recognise other clinicians since staring at someone's waist-line to read their ID card is hardly more praticable than asking every smartly dressed person in hospital for their name and position. Truth be told, there is a considerable lapse in dress-code among Zurich doctors with jeans and T-Shirt being staple items among those coming to and leaving from work. But in every other respect, I favour a clinician work uniform over the dress-smartly-roll-up-your-sleeves approach. As a patient I would rather instantly recognise doctors by rank and name and be sure in the knowledge that they are wearing freshly laundered clothes in place of privately worn attire, than appreciate the half-hearted attempt at removing perceived barriers between patients and doctors.

Rapidly evolving disciplines such as medicine are always eager for novelty, hence attention is normally directed towards the future. Yet, it is sometimes worth turning back and seeing how modern debates were tackled by the ancients. I shall use this approach to reflect on Dr. Dancer’s views about ties, scruffiness and hygiene in contemporary physicians.(1)

Concerns about doctors’ manners and attire are as old as medicine itself. Even the Hippocratics – in the sixth book of Epidemics (which does not describe any epidemic, but is an heterogeneous collection of case reports and aphoristic knowledge) - had highlighted the importance of 'attitude, clothing… hair, nails and smells',(2) around 400 BC. Some centuries later – by the 2nd century AD - Galen achieved what I am now about to attempt: he referred to the ancients in order to judge the moderns.(3) His enterprise yielded a long and celebrated commentary on Hippocrates’ Epidemics. Mine will at best offer another perspective on a current dispute.

In that work Galen tried to explain each of the terms mentioned by the father of medicine.

Firstly, when clarifying what Hippocrates meant by attitude, he interpreted ‘bodily attitude’ or ‘manners’, and stated that doctors 'should avoid all the extremes and endeavour to remain within the perfect measure' (IV.10.148, p. 205).(4) This idea of moderation permeates the whole analysis, and is also present when elucidating Hippocrates’ ideas about attire:
'Clothing…should also be intermediate, neither luxurious… nor filthy or too humble, unless your patient himself lacks a sense of measure, and loves the opulence or enjoys the filth. In these cases you can move from the right mean –as far away as you are ready to accept- in order to please your patient.' (IV.10.149, p. 205).(4)

The emphasis on the patients’ preferences appears again when Galen comments on hair and nails:
'The best haircut is the one that aims at preserving the health of the head. It changes according to [the preferences of] the patient… You will, therefore, have to pay attention to the patient that you are treating…The convenient length of the nails is that which is agreeable for those who look at them' (IV.10.150, p. 206).(4)

Finally, the explanation about smells introduces another interesting concept:
The smell can be from the whole body or from the mouth… the latter originates from negligence (IV.10.152, p. 207).(4)

In other words, according to Galen, Hippocrates meant that the physician is responsible for having bad breath: he should be more careful and try to improve it through 'cleansing beverages and remedies.' (IV.10.152, p. 206).(4)

As we can see, the topics of the debate have not changed much. Galen’s comment covers almost all the issues raised by Dr. Dancer: the discussion around appropriate attire; the importance of an adequate attitude, and of image in general; the link between these matters and health (as testified in the relationship between hairdo and head health); and the connection between untidiness and lack of care.

Perhaps the big difference between the ancient and the modern discourses lies in the emphasis…

Very cleverly, Galen avoids recommending any fashionable accessory to customize the toga. Instead, he advocates for the right mean. He is aware that manners, attire and image are not fixed values, but transient conventions that depend on personal preferences; therefore, they need to be adapted to the various cultures, places and audiences. Additionally, he suggests that the physician should compromise to a certain degree in order to please his patient, but not beyond the point where he feels comfortable.

Bringing these ideas back to the context of Dr Dancer’s article, it is beyond doubt that health and hygiene belong at the forefront of sanitary education and policy; this cannot be encouraged enough. However, equating the lack of ties with a lack of hygiene, and likening the informal attire with 'picking the nose, spitting and scratching one’s straggly hair'(1) is perhaps stretching the point.

Not all doctors need to wear a tie or a white coat to feel that ‘they are members of a distinguished profession’,(1) nor all patients would feel comfortable to undress their bodies and souls in front of somebody whose primary feature is formality. In other words, the firm and unshakable ethical laws of hygiene should not be confused with changing and adaptable etiquette. Cleanliness, and tidiness can exist in the juniors, seniors, the formal or casual. Conversely, ties, white coats and designer leather shoes do not guarantee spotlessness, unless the wearer washes both them and himself often enough.

To conclude, whilst acknowledging the important points that Dr. Dancer raised concerning the values of hygiene; I think we should encourage the Galenic flexibility to let each doctor choose his outfit according to his own preferences and the audience that he is to address, as long as he respects the unquestionable requirements of tidiness and cleanliness.
 
References:
Dancer S, Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene BMJ 2013; 346:f3211
Hippocrates, Epidemics VI 4.7 in Hippocrates Vol. 7 (Loeb Classical library) with an English translation of W.H.S Jones. Cambridge, Mass: Harvard University Press. 1952.
Jouanna J, Galen’s Reading of Hippocratic Ethics in Greek medicine from Hippocrates to Galen: selected papers. Leiden, Boston: Brill, 2012
Galen In Hippocratis Epidemiarum librum VI commentaria I-VIII. Edited by E. Wenckebach and F. Pfaff. (Corpus Medicorum Graecorum), Berolini: In aedibus Academiae Litterarum, 1956. All quotes from Galen belong to this edition. The translations are my own.
Bourgey L, Riese W. Les gracieusetés à l’égard des malades: Commentaire de Galien sur Épidémies, VI section 4, división 7, in Revue Philosohpique de la France et de l’Étranger 1960; T.150, pp. 145-162.

I have spent time on a medical student elective at an institution in Rochester, Minnesota, and at "Man's Great Hospital" where we wore freshly laundered white coats, several institutions as a trainee where I have worn a white coat or a suit and this year I would be one of the "colleagues who are quite happy to come to work in muddy trainers and exposed midriffs."

My identity as a doctor has nothing to do with my dress code although I appreciate the need for some basic professional attire and tend to go for a shirt and ironed trousers. My best response is a quote from a patient: "I had all these strange people I've never met see me every day, but I always knew that you would sit down with me and my family every day to explain things, so you're my doctor."

I cannot believe the BMJ actually published Dr Dancer's article. Inspired by the Daily Mail, no less. I read the Daily Mail about once a year, usually a free one at an airport. Each time I do, I discover afresh why they have to give it away.

So bad enough to base an article on a Daily Mail opinion piece. Even worse to conflate "scruffiness" and "untidiness" and lack of hygiene (with not-so-thinly veiled accusations of spreading infection) with absence of conservative old time Harley Street dress.

Like one of your GP respondents, I wonder how I would get through the day if I wore a suit and tie and attracted more patients---far too many want to see me as it is. Despite T shirt, jeans, casual shoes etc etc.

Ah well. Silly season again.