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

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f3211
  1. Stephanie J Dancer, consultant microbiologist, Hairmyres Hospital, East Kilbride, Lanarkshire G75 8RG, UK
  1. stephanie.dancer{at}

Informal dress among doctors may be an unexpected side effect of a ban on ties in the UK. But, asks Stephanie Dancer, does this scruffiness also reveal something about how we view hygiene today?

Not long ago an article in the Daily Mail commented unfavourably on so called scruffy doctors.1 The fashion for dressing down in the United Kingdom is a consequence of the Department of Health’s edict in 2007 that in the interest of hospital hygiene doctors should not wear ties.2

Now many junior doctors have abandoned formal wear in favour of T shirts and the like. I hear that patients complain that they do not know who the doctor is: no tie, no white coat, no jacket, and no presence. Doctors are members of a distinguished profession and should dress accordingly. Untidiness erodes the image of doctors as responsible and competent.3

Is there any evidence that staff apparel has been implicated in the transmission of pathogens to patients? None at present, although all clothes, including ties, may be covered with a range of microbial flora.4 5 Hand touch contact, airborne delivery, environmental reservoirs, and human carriage are all implicated in transmission. Given that bed linen and pyjamas are habitually contaminated with their owners’ personal microbial flora, the focus on transmission from what staff are wearing seems disproportionate and perhaps even irrelevant.6

Of course, scruffiness among doctors could also indicate something more sinister. Scruffiness is synonymous with being untidy, dishevelled, and unkempt, with having straggly hair, ill fitting clothes, and scuffed shoes—or trainers—as well as not wearing a tie and so on. Together these might be taken as a flashing neon sign that says “I don’t care.” Scruffiness, however defined, also intimates a lack of personal hygiene and correspondingly lower standards of hygienic behaviour. Personal habits such as scratching your hair or nose with your fingers contribute towards contamination of the next item or patient that you touch. Wearing the same clothes for several days showers the environment with millions of skin organisms, not all of them friendly. It could be argued that ditching the white coat and tie for hygiene purposes has had the converse effect, in that the informal attire now gracing our wards has encouraged a less robust view of infection control.

Maybe junior doctors do not understand the real meaning of cleanliness. Easy access to antibiotics has eroded the importance of basic hygiene over the past half century.7 Consider the monumental efforts required to entice us to clean our hands, for example.8 Similarly, recent public furore over so called “dirty” hospitals culminated in a costly deep clean for English hospitals.9 Was it like this before antibiotics? Twenty first century hospitals are congested and understaffed, with poor ventilation and stuffy wards.10 Hygiene is no longer appreciated as a key tool against infection, although politicians and professionals make sure that it is prodigiously mentioned in any new mandate targeting hospital acquired infections. Given that cleanliness is no longer a matter of life or death, it is no wonder our junior doctors dress the way they do.

Are medical students being made aware of the almost inevitable demise of the antimicrobial era? I suspect that students, and other healthcare trainees, are unlikely to receive any mention of hygiene principles, let alone a lecture on its escalating importance.11 The science of dirt removal might lack the excitement of the newer disciplines of interventional radiology or nanoparticles. Yet, given the future challenges of fighting infection, surely some education on hygiene might be permitted to rise, like a phoenix, from the ashes of all those squandered antibiotics.

The lack of the tie is not just a visual wave in the direction of infection control. Nor is it another tick in a box on the audit clipboard. “No tie”—along with stubble, spitting, picking your nose, and gravity defying trousers—symbolise the real status of hygiene in today’s society.12

The dress code for UK doctors was imposed more as a political gesture than as an evidence based strategy likely to reduce infections acquired in hospitals.6 13 14 In contrast, long term investment in traditional hygiene strategies would reap dividends.13 Before the antibiotics run out we need to revisit the hygiene values of the past and we need to communicate those values to the doctors of the future.7 11 15 Common sense often turns into scientific evidence at some stage; you just have to wait for it.7 How about a bow tie, gentlemen?16


Cite this as: BMJ 2013;346:f3211


  • I thank Alasdair Geddes, emeritus professor of infectious diseases, University of Birmingham, UK, who insisted upon, and inspired, the writing of this article.

  • Competing interests: the author has completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work other than the fact that the author is a woman and doesn’t wear a tie.

  • Provenance and peer review: Not commissioned, not externally peer reviewed.


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