Abstract
Background: The doctor–patient relationship is important in determining the quality of healthcare provided. This study aimed to identify patient preferences regarding dress code, conduct and resources used by doctors during consultations in the public healthcare sector, Bloemfontein. Information from this study can be of benefit in determining policies and dress codes within hospitals and medical schools.
Methods: This was a descriptive, cross-sectional study. Self-administered anonymous questionnaires were distributed at Bloemfontein's National District Hospital to patients 18 years and older, waiting in the pharmacy and consultation queues.
Results: Of the 500 questionnaires distributed 410 were analysed. Patients preferred doctors to wear formal attire. For female doctors this included a neat blouse (77.9%), smart pants (62.5%) or straight-cut jeans (51.4%) and flat pumps (56.3%). Patients preferred male doctors to wear collared shirts (52.4% and 57.6% for long- and short-sleeved shirts, respectively) with smart pants (66.8%) or straight-cut jeans (45.9%), and smart shoes (70.3%). Patients did not condone eating and drinking by doctors during consultations; work-related calls were deemed acceptable. The use of technological resources was not preferred.
Conclusion: Patients in the public healthcare sector prefer a formal, professional consulting environment that is determined largely by the doctor’s attire and conduct during the consultation.
Introduction
It is doctors’ responsibility to fulfil the medical needs and expectations of their patients, but achieving this is becoming increasingly difficult. In 2009, Mahmud stated that ‘The doctor–patient relationship is central to the practice of medicine and is essential for high-quality health care in the diagnosis and treatment of diseases.’Citation1
According to members of the Medical Professionalism Project,Citation2 ‘In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism becomes all the more important’. It is for this reason that the projectCitation2 was launched in order to aid medical professionals in their efforts to act appropriately in the medical environment. The Charter on Medical Professionalism, its principal product, consists of three fundamental principles that create the basis for the core of the charter, a set of 10 commitments. ‘Commitment to professional responsibilities’ is one of the commitments of the charter. It includes, inter alia, the way doctors dress and conduct themselves during a consultation, factors that can affect the doctor–patient relationship and the patients’ confidence in their doctor (unpublished lecture notes; Myburg J. The Doctor and the Environment, February 19, 2013). By abiding by these principles and remembering their responsibilities, doctors not only improve their interactions with patients, but also improve the healthcare system as a whole.Citation2
Universally, white coats are associated with the medical profession.Citation3 A systematic review by Petrili et al.Citation4 included 30 studies from 14 countries, involving 11 533 patients in a variety of medical settings. In 60% of these studies formal attire and white coats with other attire not specified were patients’ preference, more commonly in older patients and in studies conducted in Europe and Asia. A study in Japan found no difference between age groups, gender or region regarding the overall preference for white coats.Citation5 A Brazilian study found a patient preference for white clothing for doctors.Citation6 A small study in Hawaii found that, although by a small margin, patients did not prefer white coats. They approved of scrubs and blue jeans, but disapproved of slippers or shorts.Citation7 With changing societal norms, tattoos and piercings have become more common, but patients do not find these acceptable for healthcare workers.Citation6,8
The manner in which doctors introduce themselves as well as the manner in which they address patients are equally important. Studies have shown that most patients prefer being addressed by their first name and for the doctor to be introduced by their full name and title, all the while wearing a smile on their face.Citation9,10
Practices have had to keep abreast with advances in technology.Citation11 Computers are used in consultations as a means of history- and note-taking, and when access to the Internet is possible, they provide an easily accessible and efficient way of acquiring information about a condition, medication or prognosis. Their use has become so widespread that in a document providing consultation skill tips for new GP registrars when starting off in general practice, the strategic use of the computer in the consultation is one of the aspects covered.Citation12 The computer is considered the third party in the consultation.Citation13 In a qualitative study among family physicians, three distinct practice styles when using a computer in the consultation were found: still focused on the patient, focused on the computer, and alternating attention between the computer and the patient.Citation14 A New Zealand study of GP consultations found that use of computers interrupted the flow of the doctor–patient conversation due to silences and the doctor turning away from the patient. Doctors used various strategies to retain engagement with patients such as verbalising while typing or reading on the computer.Citation15 However, Hsu et al.Citation16 reported that after introduction of computers in the examination rooms for outpatient primary care visits, patient satisfaction with visits increased as well as their satisfaction with communication regarding medical issues and comprehension of decisions made during the visit. No significant negative effects were found.
To the researchers’ knowledge, there have been no recent similar studies in South Africa. In 2008, de GrootCitation17 expressed concern in a letter to the South African Medical Journal regarding dress codes of doctors at that time. He indicated with regret that it seemed that the white coat was no longer in favour, and made a plea that a doctor needs to be properly attired as a courtesy to the patient. The information obtained in conducting this study can be valuable in determining policies and dress codes within hospitals and medical schools. During 2014, the dress code and code of conduct for medical students at the University of the Free State (UFS) were revised with implementation from January 2015. The main revision was that medical students are now required to wear white jackets for all academic and clinical activities. The study findings could be used to determine whether the revised codes are in line with patient preferences.
Aim
This study aimed to identify the preferences of patients with regard to the dress code, conduct and resources used by doctors during consultations in the public healthcare sector in Bloemfontein, Free State.
Methods
This was a descriptive, cross-sectional study.
The study population included patients that made use of the public healthcare services at National District Hospital, Bloemfontein, Free State, from September 2014 to November 2014.
In their review article, Petrili et al.Citation4 reported that for the 30 studies included, patient numbers ranged from 77 to 1 506, thus an average of approximately 380 patients per study. The study sample for this study consisted of 500 patients aged 18 years and older, consulting doctors or pharmacy at Bloemfontein's National District Hospital. The sample size was determined taking into account the number of patients seen per day at the study location, and the number of student researchers and their time availability. Participants were chosen using a random sample by selecting every third patient waiting in the four outpatient areas or pharmacy queue. Patients under the age of 18 years and patients who were illiterate or unable to understand English, Afrikaans or Sesotho were excluded from the study.
Measurement
Data were collected by means of a self-administered, self-designed questionnaire available in English, Afrikaans and Sesotho. The questionnaire was compiled after reviewing related studies and taking the student researchers’ own experience of the local environment into account. The questionnaire consisted of four sections: demographic information of the participant, acceptable dress code and appearance for female doctors, acceptable dress code and appearance for male doctors, and aspects of the consultation.
The researchers distributed questionnaires on 10 occasions at each of the five areas over a period of three months. Participants were requested to place their completed questionnaires into a marked box that was present in each area.
Data analysis
The completed questionnaires from the main study were analysed by the Department of Biostatistics, Faculty of Health Sciences at UFS using descriptive statistics.
Pilot study
In the pilot study, the questionnaires were distributed to 15 participants: three patients from each area within the hospital.
During the pilot study the methods of participant selection, the distribution and retrieval of the questionnaires, and the time that it took to complete the questionnaires (ensuring that the time did not exceed 15 minutes) were assessed. The data of the pilot study were not included in the main study.
Ethical considerations
Approval for the study was granted by the Ethics Committee of the Faculty of Health Sciences, UFS (STUD NR 18/2014). Permission to distribute the questionnaires to the patients at the hospital was given by the CEO of Bloemfontein's National District Hospital.
Before the researchers began the distribution of the questionnaires, all the patients present in the five areas were informed of the researchers’ intentions by means of a group announcement made by either a healthcare worker or a researcher. It was stated that a study was being conducted and that they may be approached by the researchers to participate in the study.
The information sheet, attached to each questionnaire, served as a means of informed consent, emphasising that participation, or refusal thereof, would not affect the treatment and care received at the hospital. Participation was voluntary and participants were free to withdraw from the study at any time.
Results
Of the 500 questionnaires distributed at Bloemfontein's National District Hospital, 473 were returned (response rate = 94.6%). Fourteen (14) questionnaires were excluded as either none of the sections had been completed, or every option had been selected. A further 49 questionnaires were excluded since only one of the three sections dealing with the doctors’ dress code and the consultation had been completed. In total 410 questionnaires (82.0%) were included in the study.
Two-thirds (67.0%) of the participants were female. The median age of the participants was 46 years with a range of 18 to 89 years. Most participants (66.3%, 260/392) had a high-school level of education and 34.7% (136/392) had completed Grade 12. One participant had a PhD degree and 16 participants (4.1%) had not received any formal education.
The majority of participants felt that both female doctors (75.6%) and male doctors (82.0%) should wear white jackets during consultations. About 60% felt that a doctor should wear a name badge for identification. Surgical scrubs worn during a consultation were not considered acceptable (Tables and ). Several participants stated explicitly on their questionnaires that they were comfortable with theatre scrubs only in theatre.
Table 1: Acceptable appearance for female doctors.
Table 2: Acceptable appearance for male doctors.
Earrings were considered acceptable for female doctors to wear (60.7%), but only 19.3% of the participants felt that this was acceptable for male doctors. A low percentage of participants found piercings and tattoos in both female and male doctors acceptable (see Tables and ).
The majority (77.9%) of participants chose a neat blouse as their preference for shirts for a female doctor. A see-through blouse, low-cut top and an exposed midriff were deemed acceptable by less than 5% of participants. Smart pants were the most acceptable form (62.5%) of pants, followed by straight-cut jeans (51.4%). Faded jeans, torn jeans, skinny jeans, shorts, leggings and exercise pants were acceptable to less than 10% of participants. Most (79.1%) participants preferred dresses or skirts to extend below the knee. Flat pumps were acceptable to 56.3% of participants, with heels being the second most selected at 32.7%. Crocs™ were the least acceptable form of footwear (7.4%) (see Table ).
For female doctors, dyed hair was acceptable to 9.6% of the participants while 66.7% preferred long hair tied up. Almost all (94.7%) of participants favoured short nails for female doctors.
More than half of the participants selected long-sleeve collared (52.4%) and short-sleeve collared (57.6%) shirts as acceptable attire for male doctors. Only 22.4% felt that a tie was also required. Smart pants (66.8%) and straight-cut jeans (45.9%) were the most acceptable attire. Faded, torn or skinny jeans, shorts and tracksuit pants did not meet with approval in more than 5.5% of participants. Smart lace-up shoes were acceptable to 70.3% of the participants, with slops or flip-flops and Crocs™ selected by only 6.8% and 12.1%, respectively (see Table ).
Participants preferred short hair (85.1%) in male doctors, whereas long hair that had been tied up was selected by 24.2%. Dyed hair was found to be acceptable for only 4.9% of the participants.
Table shows that almost 60% of participants felt that the title ‘Doctor’ should be used when a doctor introduces him/herself. The doctor’s surname was selected by 63.2%. About half of the participants preferred to be addressed using their title (53.2%) and their surname (54.2%).
Table 3: Preferred doctor behaviour during consultation.
Eating and drinking during the consultation were deemed unacceptable by the majority of participants (91.5% and 83.8%, respectively), while 67.1% found it acceptable for their doctor to answer work-related calls during the consultation. In comparison, only 9.5% felt that taking a non-work-related call was in order.
Most (92.4%) of the participants preferred that their doctor wear gloves during the examination phase of the consultation.
Participants felt most comfortable with their doctor using a computer (39.3%) to source additional information. This was followed by their doctor seeking advice from a fellow doctor (27.8%). Only 14.4% of the participants selected cell phones as an acceptable resource. Relating to this, 70.2% of participants indicated that should doctors make use of these available resources it would not cause them to doubt their doctor’s ability. Furthermore, if the technological resources were utilised during the consultation, 68.8% of participants would prefer to be able to view the screen of the device that the doctor was using.
Discussion
The white coat serves as an easy means to identify doctors, and the participants showed a high preference for doctors to wear white coats during consultations. As 59.1% also felt that doctors should wear name badges as a form of identification, it is evident that being able to easily identify doctors in a hospital environment is important to the patients. This thus prevents the confusion regarding whether the person is the doctor, as outlined by De Groot.Citation17 Studies in Ireland as well as the United States have found that once patients are informed about the possible microbial contamination of white coats or any attire with clothing below the elbows, their preferences shift from white coat and formal attire to smart casual.Citation18,19 This aspect was not investigated in our study. Dancer and DuerdenCitation20 argue that the possible harm to the patient–doctor relationship due to the ‘loss of the white coat’ outweighs the ‘putative benefits in terms of infection control’.
In our study, participants still placed great emphasis on keeping the doctor–patient consultation formal and professional as reflected in the attire that the participants preferred for their doctors. Almost 80% of participants indicated that dresses or skirts worn by female doctors should extend to below the knee. The dress code provided by the Faculty of Health Sciences, UFS stipulates only that one’s dress/skirt must exceed the length of one’s white coat. This makes allowance for doctors who prefer to wear shorter length skirts and dresses. As with the discussion on female attire, the preferences with regard to the male dress code also tended towards that which would be seen in a formal environment. Regarding the general appearance of male doctors, participants preferred doctors to have short hairstyles and no piercings or tattoos. Similar findings were reported in Brazil.Citation6
The introduction is an essential part of the consultation as it sets the tone for the doctor–patient interaction that is to follow (unpublished lecture notes; Myburg J.). The title and surname of both the doctor and the patient are considered important during the introduction.
Patients did not condone eating and drinking by doctors during the consultation. Doctors should be sensitive to their patients’ circumstances: in the public hospital environment many patients spend hours waiting to consult a doctor or pharmacist, by which time many will be hungry and thirsty. Thus, doctors may appear to be insensitive if they eat in front of their patients.
As with the preferred dress code, patients favoured a more formal consultation in which the doctor–patient interaction is uninterrupted and the doctor’s attention is focused solely on the patient. Non-work-related calls are seen as interrupting and could potentially harm the doctor–patient relationship. This may influence the treatment provided by the doctor, as well as the patient’s compliance with this treatment (unpublished lecture notes; Myburg J.).
A study in SwitzerlandCitation21 investigated the use of the Internet by primary care physicians for medical purposes during their daily practice. The results indicated that a fear of a negative impact on the doctor–patient interaction was one of the main reasons for not using the Internet during consultations. Instead, 59% of doctors preferred to solve patient-specific problems by consulting fellow practitioners or referring to textbooks. In contrast to the doctors’ beliefs, patients felt that doctors who used computers were up-to-date with modern methods of treating illness and disease. Furthermore, effective use of computers by doctors seemed to inspire confidence in their patients and made them feel more comfortable. Patients felt that computers were intrusive only if the doctor did not make eye-contact upon their entering the room, or if the doctor appeared to be preoccupied with the computer.Citation22
In a review of 51 studies, mainly in primary care settings with approximately equal numbers being qualitative and quantitative in approach, Crampton et al.Citation23 summarised their findings as indicating that the effects of health information technology (HIT) use in consultations are complex. The direction of these effects (i.e. positive or negative) depends on ‘the combination of consultation room layout, patient and clinician styles of interaction with HIT as well as each other, and the strategies and techniques employed by clinicians to integrate HIT into consultations’. Our study showed that patients did not want their doctors to use technological resources in the consultation. However, if the doctor does refer to some form of technology, the patients would prefer to view the screen so that they are aware of what is being entered. Although this does not avoid the doctor’s attention moving away from the patient, the patient would feel more included. While patients did not want their doctors to utilise such resources, their use did not instil doubt in them regarding their doctor’s ability. A qualitative study investigating doctors’ use of small-screen handheld computers found that doctors’ actions and non-verbal communication while doing so were less clear to the patients. In addition, mobile devices may look very similar to personal devices or may even be the same as the personal device, thus the patient may not realise the doctor is indeed using their device for consultation purposes.Citation24
At public hospitals doctors usually examine patients without wearing gloves, as the practice of thorough hand washing is seen as sufficient to prevent cross-contamination between patients. The researchers expected that this approach to cross-contamination was commonly accepted by patients. However, 92.4% of the participants felt that their doctors should wear gloves during the examination. This may be difficult to achieve as public hospitals are generally lacking in the availability of resources such as gloves. Some participants may have considered the term ‘examination’ as referring to an intimate/internal examination rather than a general clinical examination.
Study limitations
In the original study design, three public hospitals in Bloemfontein were to serve as the institutions at which participants were to be interviewed. However, as two of the public hospitals failed to respond to the request for permission to conduct the study, the study population had to be limited to patients attending Bloemfontein's National District Hospital.
In the first stages of data capturing it became evident that some participants did not comprehend what was expected of them. The researchers suspect that this could be the result of a language-barrier, as several participants asked for questionnaires in languages that were not available although they had indicated verbally that they were fluent in English, Afrikaans or Sesotho. The demographic section of the questionnaire was phrased rather cryptically and these questions were often not answered. For this reason no gender or age comparisons of responses were made. In addition, researchers felt that many participants struggled with the questionnaire as a result of a poor education level. However, the results reflect that 83% of the study population had attained an education level of Grade 8 or higher, which was contrary to what was expected.
Recommendations
The use of either aided questionnaires or structured interviews with patients, although more time-consuming, would have enabled the researchers to obtain more reliable and complete data as the omission of any questions, as well as any misinterpretation of the questionnaire, would have been avoided. To further avoid confusion, visual aids could have been included with the questionnaire so that the patients would have been able to visualise precisely what the questionnaire was referring to. This would have helped patients who may not have been familiar with any of the terms used. Photographs have been used in a number of reported studies.Citation5,8,25 Choice of models for these needs careful consideration.
Further investigations could have been conducted with regard to the use of technological resources during the consultations. Some of the results obtained in this regard were slightly ambiguous and contradictory.
Further research could include doctors working in the public healthcare sector to determine what doctors feel patients expect from them. Comparing this with the results obtained from the patients would enable one to identify whether or not doctors are aware of what patients expect from them.
Conclusion
From the results obtained, the researchers were able to successfully establish an ideal dress code for male and female doctors, identify the patients’ expectations of doctors’ behaviour during the consultation, and highlight potential pitfalls of doctors during the consultation. Patients in the public healthcare sector desire a formal, strictly professional consulting environment that is determined largely by both the attire of the doctor and the conduct of the doctor during the consultation.
The motivation of the study was to compare the above findings with both the dress code and the code of conduct of the School of Medicine, Faculty of Health Sciences at the UFS. In comparing the two, it can be asserted that both the dress code and code of conduct of the School of Medicine are well aligned with the aforementioned desires of the patients. This places both medical students and doctors in good stead for establishing a successful and therapeutic doctor–patient interaction.
Acknowledgements
Appreciation is extended to the healthcare staff and patients at National District Hospital, Bloemfontein, Free State, for their contributions to this study.
Ms Theanette Mulder, Medical Editor, School of Medicine, University of the Free State, is thanked for technical and editorial preparation of the manuscript.
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