Pediatrician wearing a white coat: A survey of preferences among children and their care givers

Background: The practice of wearing white coats, also called laboratory (lab.) coats, by doctors is very common throughout the western world and is also found in the rest of the world. The exact origin of this practice is unclear and its relevance, especially in pediatric practice, is being questioned of late. Objectives: To find out whether the mode of dressing of a pediatrician, especially wearing of white coats, has an influence on the perception of the doctor by parents and/or children in a pediatric ward. Materials and Methods: A structured self-administered questionnaire was used to collect information from the caregivers of children, (and older children) who were admitted in the hospitals during the study period. Three photographs of a doctor dressed differently (formal dressing with shirt and tie and a white coat, formal dressing with shirt and tie but no white coat and casual dressing with T-shirt upon jeans trousers) were shown to the children and their parents/caregivers and were asked to indicate which of the pictures they would prefer as their child’s doctor. Results: A total of 227 child/caregiver pairs were interviewed. Ninety-four of the children [41.4%] were females whereas133 [58.6%] were males. The preference of the caregivers on the appropriate dress style for doctors was mostly the corporate attire alone was 74 [32.6%]; and with a white coat was 126 [55.5%]. The preference of the children for the corporate look was also 67 [29.4%] and the corporate look with white coat was 88 [38.7%] as the preferred attire for their attending doctor. Conclusions: Our findings suggest a preference for the wearing of white coats by pediatricians, especially among caregivers and older children.

Keywords: Children, pediatrician, white coat

The practice of wearing white coats, also called laboratory (lab.) coats, by doctors is very common throughout the western world and is also found on the rest of the world. The exact origin of this practice is unclear. Blumhagen found three major origins for this practice; ^[1] the white coat in the operating room, which seems to have originated with the concept of aseptic surgery, the white coat in the laboratory, and the white coat in hospitals. It is believed that white (laboratory) coats were originally worn by scientists until late in the nineteenth century when hospital physicians adopted this practice as well. ^[2]

Over the years the white coat has become a symbol of the physician; however, a number of pediatricians are beginning to abandon this habit in the belief that white coats could be frightening for young children, howbeit without supporting evidence. ^[3] The nature of dressing has an influence on how people are regarded and also affects the patient-doctor/ doctor-parent relationship. ^[4]

The professional appearance of a pediatrician is an important element affecting the perception of competence of the doctor among patients and their parents/guardians, thus influencing their compliance. ^[4] In pediatrics, especially in the emergency department, physicians must develop a comfortable relationship with both parents and children within a short period of time. Initial perceptions of physicians on the basis of their attire, facial expressions, and/or body language can affect the patient/parents’ level of comfort. ^[5],[6]

A study in St Mary’s Hospital, London in 1991 found that 72% of all hospital doctors and medical students wore white coats and most of them wore for more than 75% of the time. ^[7] Although medical opinion in London is changing away from the white coat, others feel they still have a positive role. In the USA, robbing ceremonies are common, and Van Der Weyden from Australia suggests that the time might be right to rediscover the white coat as a symbol of our purpose and pride as a profession. ^[8],[9]

This study was undertaken to find out whether the mode of dressing of a pediatrician, especially wearing of white coats, has an influence on the perception of the doctor by parents and/or children in a pediatric ward.

To our knowledge, no study of this nature has been conducted in a pediatric setting in the southeast, and indeed the whole of Nigeria.

Sampling frame

This study was carried out in the pediatric wards of three teaching hospitals from two southeastern states of Nigeria, namely University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla, Enugu, Enugu State University Teaching Hospital (ESUTH) (both in Enugu State) and Federal Teaching Hospital, Abakiliki (FETA) in Ebonyi State.

Recruitment of the participants

A structured self-administered questionnaire was used to collect information from the caregivers of children (and older children), who were admitted in the hospitals during the study period. In a few cases where the caregivers/children were illiterate, the questionnaire was administered to them by the investigators. Photographs of a doctor dressed in three different ways (formal dressing with shirt and tie and a white coat, formal dressing with shirt and tie but no white coat and casually dressed in a T-shirt with jeans trousers) were shown to the children and their parents/caregivers and were asked to indicate which of the pictures they would prefer as appropriate dressing for their child’s doctor. The questionnaires were filled rating the appropriateness of the doctor’s attire/appearance.

Study design

This was a descriptive cross-sectional study, involving 227 children and their caregivers seen at the pediatric wards of the three teaching hospitals between December 2012 and April 2013, the subjects were recruited by means of convenience sampling.

The questionnaire used for this study was adopted from the guidelines for creating questionnaires for children by Eric Hultsch T. ^[10]

Ethical clearance for the study was sought from the Research and Ethical Committee of the University of Nigeria Teaching Hospital Ituku/Ozalla, Enugu. Informed consent was sought from parents/caregivers of potential subjects before enrolling them into the study. In obtaining consent, the parents/caregivers and children were further informed of the voluntariness of their participation, the anonymity of the questionnaires and that they could withdraw from the study at any point in time if they so desired without any consequences. Only children and caregivers who were admitted in the pediatric wards of the aforementioned hospitals and who gave consent were included in the study. Children in a postoperative or preoperative state under medication or who were unconscious and parents/caregivers with psychiatric conditions or were not available during the doctors’ visit were excluded from the study.

Case selection

Subjects who fulfilled the inclusion criteria were consecutively recruited into the study.

Data analysis

Data obtained was analyzed using Statistical Package for the Social Sciences software (SPSS) statistical package version 15. The data was presented in frequencies and percentages and the Chi-square statistical test was used for categorical variables, the confidence limit set at 95%.

A total of 227 child/caregiver pairs were interviewed. Ninety-four of the children [41.4%] were females whereas 133 [58.6%] were males. The predominant age group among the patients was 0-5years. Among the caregivers interviewed, 209 [92.1%] were females and 18 [7.9%] were males. They were predominantly of the 30-39 age range [n = 105 (46.3)], and in most cases the caregiver was the patient’s mother [83.7%] [Table 1] and [Table 2].

The preference for caregivers on the appropriate dress style for doctors was mostly the corporate attire alone [32.6%] and the attire with a white coat [55.5%]. The compliance with the white coat by the doctors as reported by these caregivers was high [75.3%] with an equally high attestation to doctors friendliness to their children [91.6%] [Table 3].

The children also had a preference for the corporate look [29.4%] and for the corporate look with white coat [38.7%]. That pediatricians should continue to wear white coats was also the more popular opinion [62.1%] among the children [Table 4].

The reactions of the children to a doctor wearing a white coat did not vary widely though only 51 [22.5%] of the caregivers attributed their child’s reaction to fear of the doctors white coat [Table 5].

Of the children in the range 0-5yrs 37 [21.5%] reacted positively, 46 [26.7%] negatively and 40 [23.3%] were out rightly indifferent to their doctor wearing a white coat. The older ones were more likely to be friendly [55.6%] or indifferent [33.3%] to the same situation. This is shown in [Table 6].

Opinions differ on how pediatricians, and physicians in general, should dress to look trustworthy, competent and sympathetic to patients. Our study shows that more than half of the caregivers preferred doctors to wear corporate attire and white coat. In addition, a larger proportion of the caregivers also observed that most of the pediatricians who examined their children wore white coats and would like the habit to be continued. The reason adduced for this is that it “increases the respect and confidence that the caregiver has for the pediatrician”. Marino et al., ^[11] for example, found that parents mostly preferred the formally dressed doctor and least liked the informally dressed one.

Most of the caregivers in this study also noted that pediatricians who wore white coats were friendly and very caring to their wards when compared to those who dressed without white coats. This finding is corroborated by a study which noted that in a pediatric setting, 96% of the patients found doctors wearing white coats most trustful and concluded the traditional white attire provides confidence. ^[12],[13] Another examination of this issue demonstrated that children felt that the white coat made communication with the doctor easier. They also thought the white coat made the doctors look more scientific, skillful, well-informed and made them feel safer. ^[13] The importance of a name tag was also confirmed in several studies. ^[13],[14]

Over a third of all the children studied chose the picture that showed the pediatrician wearing corporate attire and white coat and also wanted pediatricians to continue to wear these white coats. This is in keeping with the findings of Matsui et al., who noted that children reacted negatively when attributes like open-toed sandals, clogs and shorts are worn by a pediatrician. They however chose the picture that showed a name tag and white coat as being adequate for a physician. ^[15] On the contrary, Armstrong noted that many people other than doctors wear white coats and that this has made it to lose its significance. ^[16] In a study, final year medical students mentioned the fact that they felt “gaining more respect” and “being more of an authority” when wearing the white coat. ^[17]

In this study, about 29% of children, especially toddlers and younger children (3-5years) chose pictures showing pediatrician with colourful attire. Twenty-two percent of the children (3-5years) also affirmed that white uniforms were frightening. However, the children who were frightened when they saw a pediatrician wearing white coats noted that the fear was not necessarily caused by the white coat but of the injections and painful procedures used on them by the pediatrician. This is similar to a study where 58% of children aged 3, 4, and 5 years preferred the picture of a clinician wearing a colorful attire and further showed that the traditional white uniform was said to be frightening in 41%. ^[18]

Majority of care givers wanted doctors to dress in white coats because it is hygienic and protective. Other studies also highlighted that caregivers thought that white coat made the doctors more hygienic, scientific, skillful, well-informed and made them feel safer. ^[19],[20]

In the history of the white coat, the term hygiene was not really mentioned. The white coat may have emerged in terms of science’s crave to satisfy medicine and it was a kind of recognition feature for medical staff in the hospital. In the UK, for example, there are certain dress codes for doctors; to facilitate in maintaining good hand and forearm washing when carrying out clinical activity, medical staff must be “bare below the elbows” i.e. roll-up long sleeves or wear short sleeves, and that clinical coats should not be worn during contact with the patient. ^[21] Wong D et al., ^[22] found the cuffs and pockets of white coats were the most highly contaminated areas. The level of bacterial contamination did not vary with the length of time a coat had been in use, but it increased with the degree of usage by the individual doctor. So basically these findings by Wong et al., ^[22] and Treakle and colleagues, ^[23] in separate studies, put forth to us to get rid of the white coat, the tie, the long sleeve with the bacterial contamination and to make a cleanliness attitude towards our patients in whatever short-sleeved clothes, are the main characteristics of a good practitioner.

Our study did not explore this hygienic aspect either but we find the forgoing augments rather interesting.

We noted with interest that the preference for the doctor in white coat increases as the age of the children increases. This could be explained; older children will appreciate doctors who are in ward coat, communicate better with them and will see them as being responsible when compared with infants and toddlers. The latter group of children may rather see the doctors in white as enemies and unfriendly. Influence of age on the choice was also shown in other studies. ^[24]

On the other hand, we noted that toddlers preferred doctors who were dressed in bright colors. Similar findings in the family practice setting showed that the younger the patients, the more accepting they tended to be in terms of casual attire. ^[25]

Our findings shows that more than half of the caregivers preferred doctors to wear corporate attire and white coat. We also conclude that pediatricians who wore white coats were friendlier, communicated better and very caring to their wards when compared to those who dressed without white coats. Further studies involving a larger population of children/caregivers over a wider geographic area and examining the protective effect of white coats or otherwise are desirable.

This work is a hospital based study. This may make the mothers to be a little biased when answering the questions since they know that doctors take care of their patient. This bias may be reduced if the study had been done in the community instead of the hospital, and if the person doing the questioning was not associated with the hospital.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.133699

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]