When Nicholas Bianchina, MD, received his white coat during the University of Colorado School of Medicine’s matriculation ceremony in 2017, he was excited to put it on. As the first person in his family to pursue becoming a doctor, the pristine coat represented years of hard work to get into medical school.
“I put it on and thought I had made it,” he said. “But like many medical students and residents, I hung up the white coat in my closet and didn’t touch it again until I became a first-time attending, when I thought, ‘Should I be wearing this white coat?’”
Now a chief medical resident in the CU Internal Medicine Residency Program, Bianchina is not alone in grappling with the decision to wear the white coat or not. For decades, the white coat has often symbolized physicians’ attire; however, in recent years, medical institutions and providers have debated whether physicians should wear it, with some arguing the coat promotes hierarchy and elitism while others claim it clarifies the physicians’ role and comforts patients.
Looking for clarity, Bianchina and fellow chief medical resident Ally Fuher, MD, researched the pros and cons of wearing a white coat, and Bianchina presented their findings as part of a CU Department of Medicine Grand Rounds presentation.
“Ally had a resident come to her in the fall who is a woman of color and said, ‘I’ve been experiencing a lot of misidentification. Nobody here thinks I’m a doctor. Do you think the white coat would help decrease this? But on the flip side, no one here really wears a white coat in our residency, so if I wear it, am I saying something? Will I get made fun of?’” Bianchina said. “That, truly, was the impetus for our conversation here today.”
An evolving history
Physicians have been wearing white coats since the late 1800s, though it is unclear exactly why the white coat became a predominant clinical practice. Some historians theorize it may be in connection to concerns about cleanliness, or to create a more “angelic” look for the profession, Bianchina explained.
Either way, its prevalence has persisted for decades, as reflected in media representations of physicians where many are seen wearing white coats in popular television shows like “ER.”
“However, we started to transition away from the white coat in the 2000s,” he said. “There are lots of reasons why people are choosing not to wear the white coat. There were concerns for infection risk. Some worried the coat promoted a sense of hierarchy and elitism, both in the standpoint of patients — being concerned that they didn’t want the physician to feel better than them — but also within the health care system. And then, ultimately, during COVID-19, we all took off our white coats and put on scrubs to care for patients, and some just never put those white coats on again.”
National research shows that while most physicians in specialties like pathology, neurosurgery, cardiology, and infectious diseases tend to prefer wearing a white coat, the majority of physicians in pediatrics, physical medicine and rehabilitation, emergency medicine, and orthopedics prefer not to.
Data also shows the percentage of physicians who prefer the white coat increases with age, with 75% of physicians who are 70 years and older supporting wearing white coats compared to 34% of physicians who are 29 years old and younger.
Where CU providers stand
At the CU Anschutz Medical Campus, white coats are not banned nor required, leaving physicians and their trainees to navigate murky waters on whether to wear the coats. To gain insight into where local health care workers stand on this issue, Bianchina and Fuher conducted a survey that garnered 214 responses from attending physicians, trainees, and advanced practice providers (such as nurse practitioners and physician assistants).
The majority of respondents said their most common attire is scrubs with a fleece or soft-shell jacket, with the second most common attire being business casual, and the third was the white coat.
Attending physicians, specifically, were most likely to wear business casual either with or without their white coat. Female attendings reported wearing white coats more often than male attendings. The vast majority of responding trainees, on the other hand, reported a preference to wear their scrubs without a white coat.
As part of the survey, Bianchina and Fuher asked why some participants wear white coats, with the top three responses being role recognition (43%), pockets (26%), and to symbolize expertise (11%). The top three reasons for not wearing a coat were personal comfort (23%), the dominant culture of the institution (16%), and concerns about infection risk (14%).
The patient perspective
Bianchina and Fuher investigated whether the reasons for wearing — or not wearing — the white coat had further evidence behind them, starting with the concerns that the white coat could put up a wall between physicians and their patients.
Despite these concerns, research indicates that may not be the case. CU Department of Medicine Chair Vineet Chopra, MBBS, MD, MSc, contributed to a 2018 study that surveyed 4,062 patients across 10 academic medical centers, asking patients to look at photos of physicians in different attire — ranging from casual clothes to a formal suit — and rate how knowledgeable, trustworthy, caring, comfortable, and approachable the physicians appeared. The results showed that the highest average ratings were for physicians who wore white coats with business casual attire.
“Other interesting findings from this study include that 53% of patients say a doctor’s dress is important to them, and 36% of patients say a physician’s attire influenced how happy they were with the care they received,” Bianchina said.
Patient preference for the white coat varies across diverse geographic regions, practice settings, and medical subspecialties, he explained. For example, one survey found that patients prefer a white coat with business casual attire for their primary care doctor; meanwhile, for emergency medicine and surgery physicians, most patients prefer for them to wear scrubs and no white coat.
“What I’d continually heard during medical school was that the white coat makes patients not want to talk to you, and that’s why we shouldn’t wear it,” he said. “But from the patient side, it appears the white coat positively impacts patients’ perception of their physician as someone who’s trustworthy, caring, and experienced.”
Bianchina suspects the reason why some patients prefer the white coat is because popular media often depicted physicians in white coats. He said that it usually is older patients who prefer the white coat, and he wonders if that preference will go away in the future, given that current media representations do not always show doctors in white coats.
“The white coat by itself cannot make a patient suddenly like you,” he said. “There are many ways to create a therapeutic alliance with patients without the white coat.”
Helping with role recognition
Several respondents in Bianchina and Fuher’s survey, particularly women, said that one of the reasons they wear their white coats is because it helps show that they are a physician to other patients and health care workers.
Studies have shown that many women have experienced being misidentified both by patients and other health care team members. In one study of internal medicine, surgery, and emergency medicine residents, 100% of women respondents reported being misidentified at least once compared to 49% of men, and 35% of women were misidentified more than eight times per month compared to 1% of men.
This matters because sex-based role misidentification is associated with lower levels of wellbeing, increased emotional exhaustion, and increased depersonalization, Bianchina explained. He noted that there has not been a study looking at racially minoritized individuals, but “we can imagine the effects are very similar.”
Wearing a white coat may be able to reduce the incidence of misidentification, as research has found that white coats increase role recognition as a physician.
“This is associated with increased patient participation, with a possible improvement in patients’ outcomes. But most importantly, the provider role identification is associated with decreased burnout and emotional exhaustion for marginalized identities,” Bianchina said.
“I think, especially for our trainees, they don’t always feel like they can speak up when they’re misidentified. I have big concerns about that and want to encourage them more often to wear the white coat,” he added. “But I also don’t want anyone to feel like they have to wear a certain piece of clothing to get the respect that they deserve.”
Infection risk
Some health providers do not wear white coats because they fear that it can pose an infection risk to patients.
“There’s a lot of literature that the white coat does harbor infection pathogens,” Bianchina said. “But the question is — does this actually differ from the other clothes that we wear?”
Research conducted by two CU Department of Medicine faculty members, Marisha Burden, MD, and Rick Albert, MD, found that there was no difference in bacteria when comparing a white coat and a newly laundered uniform at the end of an eight-hour workday.
“We still, to this day, do not have any literature that shows that white coat bacteria have been passed on to a patient and led to a health care-associated infection,” he said. “We know that white coats harbor these infectious pathogens, but all clothing does in our patient care setting. And we need more studies to evaluate if this is transmitted to patients and is linked to any actual clinical infection.”
An underutilized tool
One of the survey respondents said that although they stopped wearing a white coat for a long time, they recently purchased a white coat and plan to wear it again because they “want to be an ally for female colleagues who are compelled to wear one for role recognition.”
Another survey respondent said: “I’ve been literally laughed at by colleagues for wearing it but don’t think men realize what a privilege it is to not have to wear it.”
The responses prompted Bianchina to wonder if the white coat can be seen as allyship — meaning that if more physicians were to wear the coat, could they make it more comfortable for other providers to do the same?
“Is this a way to stand up for our colleagues who are not frequently identified as physicians?” he asked.
He noted that if a physician wears a white coat, it does not automatically mean that patients will trust them more or incidents of macro/microaggressions will decrease. However, it could have a positive impact on team dynamics, which is why he argues the white coat might be an underutilized tool.
At the same time, Bianchina has debated whether encouraging new generations of doctors to wear the white coat may reinforce the traditionally white, patriarchal image of physicians and hinder the ability for the field to evolve and become more inclusive of others.
“It may be worthwhile to talk to your teams about wearing the white coat or not,” he told the crowd of physicians. “The white coat is just a tool. It can’t totally make or break your clinical practice. If you want to not wear a white coat, you can still have the same level of patient trust and you can still be recognized as a physician.”
