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Medical Education  |   April 2016
Perceptions of US and Australian Medical Students and Instructors About Clinical Professional Attire: LAPEL Study
Author Notes
  • From Bond University School of Medicine in Gold Coast, Queensland, Australia (Dr Bramstedt and Mr Colaco); the Medical Education Unit at the University of Tasmania School of Medicine in Hobart, Australia (Ms De Silva); the Primary Care Department at Touro University California, College of Osteopathic Medicine in Vallejo (Dr Rehfield); and the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, Texas (Dr Blumenthal-Barby). Mr Colaco was a medical student at the time this study was performed. 
  • The authors made an oral presentation of this article at the Asian Medical Education Association Conference in Newcastle, New South Wales, Australia, on April 1, 2015. The article was also presented in poster format at the Touro University California Research Day in Vallejo on April 29, 2015. 
  •  *Address correspondence to Patricia L. Rehfield, DO, MPH, Associate Professor and Chair, Primary Care Department, Touro University California, College of Osteopathic Medicine, 1310 Club Dr, Mare Island, Vallejo, CA 94592-1187. E-mail: patricia.rehfield@tu.edu
     
Article Information
Medical Education
Medical Education   |   April 2016
Perceptions of US and Australian Medical Students and Instructors About Clinical Professional Attire: LAPEL Study
The Journal of the American Osteopathic Association, April 2016, Vol. 116, 244-254. doi:10.7556/jaoa.2016.049
The Journal of the American Osteopathic Association, April 2016, Vol. 116, 244-254. doi:10.7556/jaoa.2016.049
Web of Science® Times Cited: 1
Abstract

Context: White coats have long been the professional uniform of physicians. However, when physicians opt to remove the white coat, their clothing underneath is brought to the forefront and can influence how they are perceived by their patients.

Objective: To explore the perceptions of medical students and their instructors about appropriate clinical professional attire.

Methods: An anonymous, voluntary 55-question survey was electronically distributed to medical students and their instructors at 2 US and 2 Australian medical schools. The survey incorporated 30 images of sample attire, 9 demographic questions, and 16 questions regarding culture and context of clothing and accessories.

Results: In total, 411 students and 73 instructors participated in this study. The data revealed that white coats and neckties are nearly absent in Australian clinical attire. Overall, students were significantly more supportive of full facial coverage due to religious or cultural values compared with instructors (P<.001), and US medical students were significantly more supportive than Australian students (P<.001). All cohorts preferred dress code policies that directed students to avoid but not prohibit the use of perfume or cologne. Nose rings were controversial with significantly more support for use from medical students than instructors (pooled cohorts, P=.002). Medical students in both the United States and Australia indicated that they were most influenced by observing the attire of physicians at work (155 [38%]), compared with courses in medical ethics (19 [5%]), school policy (16 [4%]), or hospital policy (9 [2%]).

Conclusion: Although regional dress code practices are different in the United States compared with Australia, medical students were overall most influenced by their instructors’ attire in clinical settings.

This Medical Education theme issue introduces a new collaboration between the JAOA and the American Association of Colleges of Osteopathic Medicine (AACOM) to recruit, peer review, edit, and distribute articles through the JAOA on osteopathic medical education research and other scholarly issues related to medical education.

 
Dating back to 350 to 300 BC, the white coat has represented the uniform of physicians around the world.1 Beginning in 2007, white coats largely fell out of favor because of concerns about transmission of infectious organisms.2 In the clinical workplace (eg, hospital, outpatient clinics), we need to ask: What is acceptable or unacceptable professional attire and who decides? If the white coat that covers potentially unsuitable clothing is removed, the clothing underneath becomes the clinical uniform for social inspection. 
Physicians’ professional attire plays an important role in how they are perceived. White coats tend to garner trust and confidence from patients.3 In a survey of Canadian intensive care units,4 patients were presented photos of physicians and were asked which images best reflected attributes of a physician (eg, caring and compassionate, a team player, most capable of performing a life-saving procedure).4 Patients indicated that those in white coats were most knowledgeable and honest and most likely to provide the best overall care followed by those in scrubs, then suits, then casual attire, which received the lowest rating.4 
Without the white coat, patients may have difficulty distinguishing physicians from medical students or other health care team members who wear similar attire (eg, surgical scrubs in the operating theater). In addition, name tags or identification badges are often not visible. Although some patients may prefer white coats,5-7 unsupported claims have been made that such coats can carry infectious organisms that may be detrimental in hospital wards and clinics.8-10 In the absence of the white coat, a physician’s clothing must be assessed for appropriateness and professionalism. Our multi-institutional study explored the perceptions of medical students and their instructors about appropriate professional clinical attire. Aiming to understand what informs perceptions of appropriateness, the present study (or, the LAPEL study) recognizes the multicultural nature of student and instructor cohorts, as well as climate variations across continents. 
Methods
This research was reviewed and approved by the Bond University Human Research Ethics Committee on behalf of Bond University and the University of Tasmania (#RO1785), the Touro University Institutional Review Board (#M-1913), and the Baylor College of Medicine Institutional Review Board (#H-34415). 
We used a nonexperimental research design with osteopathic and allopathic medical student and instructor convenience samples at 2 medical schools in the United States and 2 in Australia. Sample size calculations determined that 327 student and 234 instructor participants were needed. An anonymous, voluntary questionnaire was distributed to 2198 osteopathic and allopathic medical students across all years and to 196 instructors using a SurveyMonkey survey. We did not reach the sample size calculation for instructors because the total number of instructors at all 4 schools was 196. From February 2014 to March 2014, the link was sent by means of email (with 1 reminder 2 weeks later) to cohorts at 2 US universities (Touro University California, College of Osteopathic Medicine in Vallejo and Baylor College of Medicine in Houston, Texas) and 2 Australian universities (Bond University School of Medicine in Gold Coast, Queensland, and the University of Tasmania School of Medicine in Hobart). 
The online questionnaire consisted of 55 questions that comprised 9 demographic questions, 16 questions regarding culture and context of clothing and accessories, and 30 questions seeking an opinion about the suitability of presented attire while working with real patients and standardized patients. These questions were based on those used in previous studies.3,11 Image distractions (eg, face, briefcase, mobile phone) in questions were obscured so as not to introduce bias. 
Data were analyzed using 2-tailed χ2 and Fisher exact tests (df=1) with QuickCalcs (GraphPad Software, Inc). Specifically, a χ2 test was used whenever the cell size involved 5 or more observations, and the Fisher exact test was used with 4 or fewer observations. A P value less than .05 was considered statistically significant. Sample size calculations were performed with a 95% confidence level. We did not receive delivery receipts and thus do not know how many e-mails were invalid. 
Results
Of the 2198 students who were sent the survey, 411 completed it, accounting for an 18.7% response rate (Table 1). Of 196 instructors who were also sent the survey, 73 completed it, accounting for a 36.7% response rate. Of 411 students, 258 (63%) were women, and 344 (84%) were aged 20 to 30 years. Student response was fairly equally balanced across years 1 through 4 of degree progression (20%, 24%, 19%, and 26%, respectively). Of the 73 instructors, 42 (58%) were women, 30 (41%) were aged 51 to 60 years, and 22 (30%) had 6 to 10 years of teaching experience. Most US and Australian instructors also worked in clinical practice (43 [77%] and 11 [65%], respectively). Notably, 1 US instructor and 2 Australian instructors wore white coats in their clinical practice. 
Table 1.
Demographics of US and Australian Medical Students and Instructors Surveyed About Professional Attire (N=484)
Characteristicsa Response Rate, No. (%)
Students (n=411) Instructors (n=73)
  Study Site
   Bond University School of Medicine 47 (13.6) 13 (18.3)
   University of Tasmania School of Medicine 143 (24.9) 43 (71.7)
   Touro University California, College of Osteopathic Medicine 123 (22.8) 16 (24.6)
   Baylor College of Medicine 98 (13.3) 1 (0.3)
   Overall 411 (18.7) 73 (36.7)b
  Age, y
   20-30 344 (84)
   51-60 30 (41)
     Men 156 (38) 30 (42)
  Highest-Earned Academic Degree
   None 160 (39)c
   Bachelor’s 195 (47)
   MD/DO/MBBS 40 (55)
   PhD 15 (21)
  Experience,d, Y
   1 84 (20)
   2e 100 (24)
   3 79 (19)
   4 105 (26)
   5 42 (10)
   6 1 (0.2)
   0-5 15 (21)
   6-10 22 (30)
   11-15 11 (15)
   16-20 9 (12)
   >20 15 (21)

a Not all participants answered all questions.

b Overall response rate for instructors excludes Baylor College of Medicine because of their substantial lack of participation.

c Bond University School of Medicine and the University of Tasmania School of Medicine have 5-year undergraduate programs. Students may enter the program after high school with no degree required.

d Years in school for students; years in teaching for instructors.

e First-year students at Bond University School of Medicine had progressed to year 2 status at the time the survey was administered.

Table 1.
Demographics of US and Australian Medical Students and Instructors Surveyed About Professional Attire (N=484)
Characteristicsa Response Rate, No. (%)
Students (n=411) Instructors (n=73)
  Study Site
   Bond University School of Medicine 47 (13.6) 13 (18.3)
   University of Tasmania School of Medicine 143 (24.9) 43 (71.7)
   Touro University California, College of Osteopathic Medicine 123 (22.8) 16 (24.6)
   Baylor College of Medicine 98 (13.3) 1 (0.3)
   Overall 411 (18.7) 73 (36.7)b
  Age, y
   20-30 344 (84)
   51-60 30 (41)
     Men 156 (38) 30 (42)
  Highest-Earned Academic Degree
   None 160 (39)c
   Bachelor’s 195 (47)
   MD/DO/MBBS 40 (55)
   PhD 15 (21)
  Experience,d, Y
   1 84 (20)
   2e 100 (24)
   3 79 (19)
   4 105 (26)
   5 42 (10)
   6 1 (0.2)
   0-5 15 (21)
   6-10 22 (30)
   11-15 11 (15)
   16-20 9 (12)
   >20 15 (21)

a Not all participants answered all questions.

b Overall response rate for instructors excludes Baylor College of Medicine because of their substantial lack of participation.

c Bond University School of Medicine and the University of Tasmania School of Medicine have 5-year undergraduate programs. Students may enter the program after high school with no degree required.

d Years in school for students; years in teaching for instructors.

e First-year students at Bond University School of Medicine had progressed to year 2 status at the time the survey was administered.

×
We compared the practice of wearing white coats by medical students in the United States and Australia (Table 2). Both by school policy and by personal choice, white coats were predominantly worn by US medical student participants compared with Australian medical student participants. 
Table 2.
A Comparison of US and Australian Medical Students’ Practice of Wearing White Coatsa
Agreement Statement US Students (n=224)b AUST Students (n=189) P Valuesc
   I am required to wear a white coat per school policy. 187 (83) 2 (1) <.001
   I wear a white coat by personal choice. 28 (13) 1 (<1) <.001
   I do not wear a white coat—it is optional at my school. 8 (4) 11 (6) .35
   I do not wear a white coat—it is not part of my school dress code. 1 (<1) 175 (93) <.001

a Statements pertained to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Three responses were duplicates, but they could not be removed because the data were anonymous.

b A P value less than .05 was determined to be statistically significant using Fisher exact test.

Abbreviation: AUST, Australian.

Table 2.
A Comparison of US and Australian Medical Students’ Practice of Wearing White Coatsa
Agreement Statement US Students (n=224)b AUST Students (n=189) P Valuesc
   I am required to wear a white coat per school policy. 187 (83) 2 (1) <.001
   I wear a white coat by personal choice. 28 (13) 1 (<1) <.001
   I do not wear a white coat—it is optional at my school. 8 (4) 11 (6) .35
   I do not wear a white coat—it is not part of my school dress code. 1 (<1) 175 (93) <.001

a Statements pertained to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Three responses were duplicates, but they could not be removed because the data were anonymous.

b A P value less than .05 was determined to be statistically significant using Fisher exact test.

Abbreviation: AUST, Australian.

×
Table 3 compares students and instructors in their opinions about dress code policies and various items of clinical attire, such as neckties, perfume or cologne, piercings, surgical scrubs, tattoos, and white coats. Our data confirm that a white coat and necktie for men is accepted in the United States even though 13 US instructors (81%) responded that it is permissible to have a different standard of dress for a medical student vs a practicing physician. In the United States, 14 instructors (88%) and 130 medical students (58%) responded that white coats should be routine attire in clinical practice, whereas 24 Australian instructors (43%) and 111 medical students (59%) indicated that white coats should not be worn. Similarly, Australian medical students were significantly more prohibitive of neckties than US medical students (64 [34%] vs 26 [16%]; P<.001). Regarding full facial coverage due to religious or cultural values, medical students overall were significantly more supportive compared with instructors (236 [58%] vs 25 [34%]; P<.001), and US students were significantly more supportive than Australian medical students (145 [66%] vs 91 [48%]; P<.001). 
Table 3.
US and Australian Medical Students' and Instructors’ Perceptions About Professional Attire in Clinical Practicea
Agreement Statement Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Overall Perceptions
   Your concept of what is appropriate professional attire has changed over time. 105 (47) 97 (51) .42 9 (56) 26 (46) .68 35 (49) 202 (49) .96
   It is permissible to have a different standard of dress for a medical student and a practicing physician. 105 (47) 84 (44) .69 13 (81) 19 (34) <.001b 32 (44) 189 (46) .94
  Professional Attire
   White coat should be routine attire. 130 (58) 24 (13) <.001b 14 (88) 20 (36) <.001b 34 (47) 154 (38) .16
   White coat should be optional. 78 (35) 52 (28) .15 1 (6) 12 (21) .27 13 (18) 130 (32) .03b
   White coat should not be worn. 15 (7) 111 (59) <.001b 1 (6) 24 (43) .007c 25 (35) 126 (31) .59
   Surgical scrubs are suitable in lieu of other attire. 171 (77) 132 (70) .15 9 (56) 39 (70) .37 48 (67) 303 (74) .27
   Excluding the operating theater, it is appropriate for the clinical setting to affect the choice of professional attire. 209 (94) 165 (88) .08 16 (94) 45 (80) .33 61 (84) 374 (91) .04b
   Neckties should be worn by all male medical students. 29 (13) 6 (3) <.001b 3 (18) 4 (7) .34 7 (10) 35 (9) .92
   Neckties should be prohibited for medical students. 26 (16) 64 (34) <.001b 3 (18) 16 (29) .53 19 (26) 100 (24) .83
   Dress code policies should permit full facial coverage due to religious or cultural beliefs or customs. 145 (66) 91 (48) <.001b 9 (53) 16 (29) .08 25 (34) 236 (58) <.001b
  Perfume or Cologne, Piercings, and Tattoos
   Dress code policies should prohibit perfume and cologne. 36 (16) 6 (3) <.001b 6 (35) 3 (5) .004c 9 (12) 40 (10) .64
   Dress code policies should indicate the avoidance of perfume and cologne. 133 (59) 65 (35) <.001b 9 (53) 27 (48) .95 36 (49) 198 (48) .94
   Dress code policies should not address perfume and cologne. 55 (25) 117 (62) <.001b 2 (12) 26 (46) .01c 28 (38) 172 (42) .003b
   Earrings should be allowed. 175 (80) 167 (88) .03b 12 (75) 43 (80) .73 55 (79) 342 (83) .41
   Nose rings should be allowed. 75 (34) 63 (33) .93 4 (25) 6 (11) .22 10 (14) 138 (34) .002b
   Facial piercings (eg, eyebrow) should be allowed. 28 (13) 28 (15) .66 4 (25) 5 (9) .19 9 (13) 56 (14) .86
   Lip piercings should be allowed. 23 (10) 21 (11) .97 2 (13) 2 (4) .22 4 (6) 44 (11) .28
   Tongue piercings should be allowed. 24 (11) 28 (15) .31 2 (13) 2 (4) .22 4 (6) 52 (13) .11
   Dress code policy should not address piercings. 55 (25) 32 (17) .06 3 (19) 14 (26) .74 17 (24) 87 (21) .68
   Visible tattoos must always be covered. 79 (35) 81 (43) .15 5 (29) 25 (45) .40 30 (41) 160 (39) .79
   Visible tattoos must be covered only if they depict violence, obscenity, or pornography. 122 (55) 96 (51) .36 9 (53) 27(48) .95 36 (49) 218 (53) .69
   Visible tattoos do not require covering. 23 (10) 13 (7) .003b 3 (18) 4 (7) .34 7 (10) 36 (9) .68

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using 2-tailed χ2 (df=1).

c Statistically significant using Fisher exact test (P<.05).

d Only eyes visible.

Abbreviation: AUST, Australian.

Table 3.
US and Australian Medical Students' and Instructors’ Perceptions About Professional Attire in Clinical Practicea
Agreement Statement Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Overall Perceptions
   Your concept of what is appropriate professional attire has changed over time. 105 (47) 97 (51) .42 9 (56) 26 (46) .68 35 (49) 202 (49) .96
   It is permissible to have a different standard of dress for a medical student and a practicing physician. 105 (47) 84 (44) .69 13 (81) 19 (34) <.001b 32 (44) 189 (46) .94
  Professional Attire
   White coat should be routine attire. 130 (58) 24 (13) <.001b 14 (88) 20 (36) <.001b 34 (47) 154 (38) .16
   White coat should be optional. 78 (35) 52 (28) .15 1 (6) 12 (21) .27 13 (18) 130 (32) .03b
   White coat should not be worn. 15 (7) 111 (59) <.001b 1 (6) 24 (43) .007c 25 (35) 126 (31) .59
   Surgical scrubs are suitable in lieu of other attire. 171 (77) 132 (70) .15 9 (56) 39 (70) .37 48 (67) 303 (74) .27
   Excluding the operating theater, it is appropriate for the clinical setting to affect the choice of professional attire. 209 (94) 165 (88) .08 16 (94) 45 (80) .33 61 (84) 374 (91) .04b
   Neckties should be worn by all male medical students. 29 (13) 6 (3) <.001b 3 (18) 4 (7) .34 7 (10) 35 (9) .92
   Neckties should be prohibited for medical students. 26 (16) 64 (34) <.001b 3 (18) 16 (29) .53 19 (26) 100 (24) .83
   Dress code policies should permit full facial coverage due to religious or cultural beliefs or customs. 145 (66) 91 (48) <.001b 9 (53) 16 (29) .08 25 (34) 236 (58) <.001b
  Perfume or Cologne, Piercings, and Tattoos
   Dress code policies should prohibit perfume and cologne. 36 (16) 6 (3) <.001b 6 (35) 3 (5) .004c 9 (12) 40 (10) .64
   Dress code policies should indicate the avoidance of perfume and cologne. 133 (59) 65 (35) <.001b 9 (53) 27 (48) .95 36 (49) 198 (48) .94
   Dress code policies should not address perfume and cologne. 55 (25) 117 (62) <.001b 2 (12) 26 (46) .01c 28 (38) 172 (42) .003b
   Earrings should be allowed. 175 (80) 167 (88) .03b 12 (75) 43 (80) .73 55 (79) 342 (83) .41
   Nose rings should be allowed. 75 (34) 63 (33) .93 4 (25) 6 (11) .22 10 (14) 138 (34) .002b
   Facial piercings (eg, eyebrow) should be allowed. 28 (13) 28 (15) .66 4 (25) 5 (9) .19 9 (13) 56 (14) .86
   Lip piercings should be allowed. 23 (10) 21 (11) .97 2 (13) 2 (4) .22 4 (6) 44 (11) .28
   Tongue piercings should be allowed. 24 (11) 28 (15) .31 2 (13) 2 (4) .22 4 (6) 52 (13) .11
   Dress code policy should not address piercings. 55 (25) 32 (17) .06 3 (19) 14 (26) .74 17 (24) 87 (21) .68
   Visible tattoos must always be covered. 79 (35) 81 (43) .15 5 (29) 25 (45) .40 30 (41) 160 (39) .79
   Visible tattoos must be covered only if they depict violence, obscenity, or pornography. 122 (55) 96 (51) .36 9 (53) 27(48) .95 36 (49) 218 (53) .69
   Visible tattoos do not require covering. 23 (10) 13 (7) .003b 3 (18) 4 (7) .34 7 (10) 36 (9) .68

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using 2-tailed χ2 (df=1).

c Statistically significant using Fisher exact test (P<.05).

d Only eyes visible.

Abbreviation: AUST, Australian.

×
Compared with their Australian peers, US students and instructors were significantly more supportive of dress code policies that prohibit the use of perfume or cologne by students in clinical settings (US instructors, 6 [35%] vs Australian instructors, 3 [5%]; P=. 004; US students, 36 [16%] vs Australian students, 6 [3%]; P<.001) (Table 3). Nonetheless, all cohorts reported that they preferred dress code policies to direct students to avoid these products rather than to prohibit their use. Nose rings were controversial, with significantly more support for use indicated by students than by their instructors (pooled cohorts, 138 [34%] vs 10 [14%]; P=.002). 
Table 4 compares students and instructors in their opinions about the suitability of various forms of footwear in clinical settings. Medical students in the United States are more accepting of casual footwear, such as tennis shoes, running shoes, and various boots (including hiking boots) in clinical settings, compared with Australian medical students. Stilettos were viewed as unacceptable clinical footwear by significantly more Australian medical students than US medical students (156 [83%] vs 127 [57%]; P<.001). Rubber clogs, commonly marketed to health care professionals, were viewed as inappropriate footwear by significantly more Australian medical students than their US peers (137 [73%] vs 67 [30%]; P<.001). 
Table 4.
US and Australian Medical Students' and Instructors’ Perceptions About Footwear Restrictions
Type of Footwear Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Sneakers 51 (23) 85 (45) <.001b 5 (29) 26 (46) .34 31 (43) 136 (33) .16
  Running shoesa 111 (50) 136 (73) <.001b 9 (60) 34 (61) .96 43 (61) 247 (61) .96
  Stilettos 78 (35) 115 (61) <.001b 8 (47) 34 (61) .47 42 (58) 193 (47) .13
  Stilettosa 127 (57) 156 (83) <.001b 12 (75) 48 (86) .45 60 (83) 283 (69) .02b
  Open-toed shoes 141 (64) 122 (64) .93 12 (71) 29 (52) .28 41 (56) 263 (64) .24
  Women's no heel, closed toe 59 (27) 59 (31) .35 3 (19) 11 (20) 1.0 14 (20) 118 (29) .15
  Women's low heel, closed toe 13 (6) 13 (7) .80 2 (13) 4 (7) .61 6 (8) 26 (6) .68
  Women's mid heel, closed toe 15 (7) 54 (29) <.001b 1 (6) 12 (21) .27 13 (18) 69 (17) .92
  Boots 18 (8) 23 (12) .24 1 (6) 5 (9) 1.0 6 (8) 41 (19) .80
  Hiking bootsa 104 (47) 102 (54) .15 7 (44) 14 (25) .25 21 (29) 206 (50) .002b
  Ugg bootsa 190 (85) 181 (96) <.001b 12 (75) 51 (91) .10 63(88) 371 (90) .70
  Cowboy bootsa 91 (41) 137 (73) <.001b 8 (50) 26 (46) .80 34 (47) 228 (55) .25
  Sandals 153 (70) 130 (68) .89 11 (65) 31 (55) .69 42 (58) 283 (69) .07
  Sandalsa 203 (91) 179 (95) .17 15 (94) 49 (88) .67 64 (89) 382 (92) .42
  Thong sandals 193 (88) 175 (92) .20 14 (82) 51 (91) .57 65 (89) 368 (90) .85
  Clogsa 67 (30) 137 (73) <.001b 4 (25) 28 (50) .09 32 (44) 204 (50) .51
  Men's Oxford dress shoesa 4 (2) 7 (4) .36 1 (6) 2 (4) .54 3 (4) 11 (3) .44
  Men's boat shoesa 40 (18) 53 (28) .02b 3 (19) 9 (16) .72 12 (17) 93 (23) .34

a Medical students and instructors were shown an image of this footwear.

b Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian.

Table 4.
US and Australian Medical Students' and Instructors’ Perceptions About Footwear Restrictions
Type of Footwear Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Sneakers 51 (23) 85 (45) <.001b 5 (29) 26 (46) .34 31 (43) 136 (33) .16
  Running shoesa 111 (50) 136 (73) <.001b 9 (60) 34 (61) .96 43 (61) 247 (61) .96
  Stilettos 78 (35) 115 (61) <.001b 8 (47) 34 (61) .47 42 (58) 193 (47) .13
  Stilettosa 127 (57) 156 (83) <.001b 12 (75) 48 (86) .45 60 (83) 283 (69) .02b
  Open-toed shoes 141 (64) 122 (64) .93 12 (71) 29 (52) .28 41 (56) 263 (64) .24
  Women's no heel, closed toe 59 (27) 59 (31) .35 3 (19) 11 (20) 1.0 14 (20) 118 (29) .15
  Women's low heel, closed toe 13 (6) 13 (7) .80 2 (13) 4 (7) .61 6 (8) 26 (6) .68
  Women's mid heel, closed toe 15 (7) 54 (29) <.001b 1 (6) 12 (21) .27 13 (18) 69 (17) .92
  Boots 18 (8) 23 (12) .24 1 (6) 5 (9) 1.0 6 (8) 41 (19) .80
  Hiking bootsa 104 (47) 102 (54) .15 7 (44) 14 (25) .25 21 (29) 206 (50) .002b
  Ugg bootsa 190 (85) 181 (96) <.001b 12 (75) 51 (91) .10 63(88) 371 (90) .70
  Cowboy bootsa 91 (41) 137 (73) <.001b 8 (50) 26 (46) .80 34 (47) 228 (55) .25
  Sandals 153 (70) 130 (68) .89 11 (65) 31 (55) .69 42 (58) 283 (69) .07
  Sandalsa 203 (91) 179 (95) .17 15 (94) 49 (88) .67 64 (89) 382 (92) .42
  Thong sandals 193 (88) 175 (92) .20 14 (82) 51 (91) .57 65 (89) 368 (90) .85
  Clogsa 67 (30) 137 (73) <.001b 4 (25) 28 (50) .09 32 (44) 204 (50) .51
  Men's Oxford dress shoesa 4 (2) 7 (4) .36 1 (6) 2 (4) .54 3 (4) 11 (3) .44
  Men's boat shoesa 40 (18) 53 (28) .02b 3 (19) 9 (16) .72 12 (17) 93 (23) .34

a Medical students and instructors were shown an image of this footwear.

b Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian.

×
Students and instructors were asked to view a collection of 18 clothing ensemble images (9 men’s and 9 women’s) and indicate their appropriateness for the clinical setting (Table 5). Images of men not wearing a necktie were judged as suitable more often by Australian medical students and instructors than by their US counterparts. Conversely, when a necktie was present, US medical students and instructors found the images more suitable than their Australian counterparts. Jeans, untucked shirts, and T-shirts on men were generally viewed as unsuitable attire by all cohorts. Women’s dresses with either low-cut necklines or short lengths were also generally viewed as unsuitable; however, men were more supportive than women. Cultural attire (eg, women’s churidar kameez [Indian tight trousers with tunic] worn with thong sandals) was viewed as inappropriate clinical attire significantly more often by students than instructors (pooled cohorts, 297 [72%] vs 41 [57%]; P=.02). 
Table 5.
US and Australian Medical Students' and Instructors' Perceptions About Inappropriate Professional Attire in Clinical Practicea
Attire Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Men's Attire
   Business suit with necktie 101 (46) 113 (60) .01c 8 (50) 30 (54) .80 38 (53) 214 (53) .98
   Slacks and long-sleeve dress shirt, no necktie 31 (14) 5 (3) <.001c 4 (29) 2 (4) .01b 6 (9) 36 (9) .96
   Slacks and long-sleeve dress shirt, with necktie 9 (4) 39 (21) <.001c 2 (13) 12 (22) .72 14 (20) 48 (12) .08
   Slacks and untucked dress shirt 193 (86) 167 (88) .60 13 (87) 38 (68) .20 51 (72) 360 (87) .002c
   Jeans, blazer, dress shirt, no necktie 164 (73) 115 (61) .01c 14 (88) 30 (54) .02b 44 (61) 279 (67) .36
   Jeans, dress shirt, no necktie, no blazer 194 (87) 142 (76) .003c 15 (94) 39 (70) .06 54 (75) 336 (82) .22
   Chino pants, polo shirt 98 (44) 125 (66) <.001c 7 (44) 14 (25) .25 21 (29) 223 (54) <.001c
   Casual pants, T-shirt 204 (92) 175 (94) .64 15 (94) 48 (86) .67 63 (88) 379 (93) .21
   Chino pants, denim shirt 116 (52) 88 (47) .34 12 (75) 13 (23) <.001b 25 (35) 204 (50) .03c
  Women's Attire
   Dress (low neckline) 200 (90) 178 (95) .12 15 (94) 51 (91) <.99 66 (92) 378 (92) .88
   Minidress 184 (83) 143 (76) .09 13 (81) 42 (76) <.99 55 (75) 327 (80) .81
   Business suit 30 (13) 28 (15) .77 3 (19) 3 (5) .12 6 (8) 58 (14) .25
   Jeans, blazer, casual top 157 (70) 105 (56) .003c 14 (93) 21 (38) <.001b 35 (49) 262 (64) .03c
   Jeans, dress shirt 186 (83) 133 (71) .38 14 (88) 32 (57) .04b 46 (64) 319 (77) .02c
   Dress slacks, untucked blouse 59 (26) 60 (32) .27 6 (38) 17 (30) .81 23 (32) 119 (29) .71
   Casual pants, casual untucked shirt 63 (29) 51 (27) .86 5 (31) 7 (13) .17 12 (17) 114 (28) .08
   Skirt, tucked blouse 11 (5) 9 (5) .94 2 (13) 2 (4) .22 4 (6) 20 (5) .77
   Churidar kameez with flip flops sandals (Indian tight trousers with tunic) 163 (73) 134 (71) .76 11 (69) 30 (54) .43 41 (57) 297 (72) .02c

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using Fisher exact test (P<.05).

c Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian

Table 5.
US and Australian Medical Students' and Instructors' Perceptions About Inappropriate Professional Attire in Clinical Practicea
Attire Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Men's Attire
   Business suit with necktie 101 (46) 113 (60) .01c 8 (50) 30 (54) .80 38 (53) 214 (53) .98
   Slacks and long-sleeve dress shirt, no necktie 31 (14) 5 (3) <.001c 4 (29) 2 (4) .01b 6 (9) 36 (9) .96
   Slacks and long-sleeve dress shirt, with necktie 9 (4) 39 (21) <.001c 2 (13) 12 (22) .72 14 (20) 48 (12) .08
   Slacks and untucked dress shirt 193 (86) 167 (88) .60 13 (87) 38 (68) .20 51 (72) 360 (87) .002c
   Jeans, blazer, dress shirt, no necktie 164 (73) 115 (61) .01c 14 (88) 30 (54) .02b 44 (61) 279 (67) .36
   Jeans, dress shirt, no necktie, no blazer 194 (87) 142 (76) .003c 15 (94) 39 (70) .06 54 (75) 336 (82) .22
   Chino pants, polo shirt 98 (44) 125 (66) <.001c 7 (44) 14 (25) .25 21 (29) 223 (54) <.001c
   Casual pants, T-shirt 204 (92) 175 (94) .64 15 (94) 48 (86) .67 63 (88) 379 (93) .21
   Chino pants, denim shirt 116 (52) 88 (47) .34 12 (75) 13 (23) <.001b 25 (35) 204 (50) .03c
  Women's Attire
   Dress (low neckline) 200 (90) 178 (95) .12 15 (94) 51 (91) <.99 66 (92) 378 (92) .88
   Minidress 184 (83) 143 (76) .09 13 (81) 42 (76) <.99 55 (75) 327 (80) .81
   Business suit 30 (13) 28 (15) .77 3 (19) 3 (5) .12 6 (8) 58 (14) .25
   Jeans, blazer, casual top 157 (70) 105 (56) .003c 14 (93) 21 (38) <.001b 35 (49) 262 (64) .03c
   Jeans, dress shirt 186 (83) 133 (71) .38 14 (88) 32 (57) .04b 46 (64) 319 (77) .02c
   Dress slacks, untucked blouse 59 (26) 60 (32) .27 6 (38) 17 (30) .81 23 (32) 119 (29) .71
   Casual pants, casual untucked shirt 63 (29) 51 (27) .86 5 (31) 7 (13) .17 12 (17) 114 (28) .08
   Skirt, tucked blouse 11 (5) 9 (5) .94 2 (13) 2 (4) .22 4 (6) 20 (5) .77
   Churidar kameez with flip flops sandals (Indian tight trousers with tunic) 163 (73) 134 (71) .76 11 (69) 30 (54) .43 41 (57) 297 (72) .02c

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using Fisher exact test (P<.05).

c Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian

×
When instructors were asked whether a physician’s attire influenced patients’ opinion of the physician’s knowledge, experience, competency or skill, and professionalism, they ranked professionalism highest and knowledge lowest. Similarly, when instructors were asked whether a medical student’s appearance influenced patients’ opinions of their knowledge experience, competency or skill, and professionalism, they ranked professionalism highest and knowledge lowest. Medical students’ answers reflected identical findings. 
Students and instructors were presented with 9 variables: (1) coursework in medical ethics and professionalism, (2) having a parent who is a physician, (3) hospital policy, (4) observing the attire of physicians at work, (5) personal experience as a patient, (6) personal upbringing in general, (7) professional codes of conduct, (8) school policy, and (9) television and media exposure. The participants were asked to choose which variable most influenced their values about the concept of professional attire in clinical situations. Instructors in both the United States and Australia indicated they were most influenced by their upbringing (21 [29%]), whereas having a physician as a parent and television and media exposure were not influential. Hospital policy and coursework in medical ethics and professionalism were the primary influencers for 2 US instructors and 1 Australian instructor. 
Students in both the United States and Australia indicated they were most influenced by observing the attire of physicians at work (155 [38%]). Upbringing was a major influencer for 110 students (27%), and courses in medical ethics (19 [5%]), school policy (16 [4%]), and hospital policy (9 [2%]) ranked low as being influential. 
Because Touro University California, College of Osteopathic Medicine is an osteopathic medical school and Baylor College of Medicine, Bond University school of Medicine, and University of Tasmania School of Medicine are allopathic medical schools, we compared data between osteopathic and allopathic medical students. Accounting for the cultural differences of white coat and necktie preferences across the United States and Australia, these student groups were much the same. Of 288 allopathic medical students, 182 (63%) were women, and 76 of 123 osteopathic medical students (62%) were women. Also, 244 of 288 allopathic medical students (85%) and 100 of 123 osteopathic medical students (81%) were aged 20 to 30 years. Both groups indicated that the primary influence over their values about professional attire was observing the attire of physicians at work. Significantly more osteopathic medical students indicated that dress code policies should prohibit perfume or cologne compared with allopathic medical students (29 [23.6%] vs 13 [4.6%]; P<.001). 
Discussion
Professional attire, a subset of professionalism, encompasses clothing, footwear, jewelry, perfume or cologne, piercings, and tattoos. Most of the studies3-7 about professional attire published in the medical literature pertain to the perception of patients regarding the dress of their health care professionals. Although the white coat has served as a visible and trustworthy badge of the medical profession,12 some physicians are opting to remove white coats from the dress code, as evidenced by the findings in the current study. 
We speculate that the lack of white coats and neckties worn by Australian physicians was influenced by the decision of the United Kingdom’s Department of Health to recommend to end the use of white coats owing to their potential to transmit infectious organisms.13 However, studies8-10 have concluded that the real issue is not the coat but rather the failure to wear clean coats. One reason that physicians continue to wear dirty coats is many hospitals no longer provide laundry services for their staff. Medical students may be unable to afford laundry and ironing services for multiple coats, and busy physicians may find little time for these tasks. On-site hospital laundry services that clean and deliver batches of coats to their staff each week is an extra service that is not standard. 
In a small study,14 neckties were found to be relatively clean in hospitals. Specifically, bacteria cultured were present in “very small numbers” and required enrichment medium to produce large numbers. Additionally, the authors found less nonhemolytic Bacillus cultured from the study neckties than the control neckties.14 Comfort and risk of physical harm (eg, strangulation) could be other reasons for omitting neckties from professional attire. Much policy attention has focused on neckties and white coats as harmful vectors, but little regard has been given to the stethoscopes dangling from physicians’ necks.15 Because Australian physicians rarely wear white coats and neckties, the adorning stethoscope has become an accessory that identifies them as a physician. Unlike other wardrobe elements, stethoscopes can be easily cleaned between each patient use, but this often does not happen.16 This topic is an important part of hygiene education whether or not white coats are worn. 
Additionally, compared with allopathic physicians, osteopathic physicians, who are trained to provide osteopathic manipulative treatment, may have closer physical contact with their patients. In the current study, notably more osteopathic medical students compared with their allopathic counterparts indicated that dress code policies should prohibit perfume or cologne. Because of the close contact osteopathic physicians have with their patients, an osteopathic physician’s attire, including visible jewelry, perfume or cologne, and tattoos, could potentially adversely affect the patient-physician relationship more than that of allopathic physicians. Given that physician attire can affect the patient-physician relationship, attire must be chosen carefully.3,6 
The potential for tensions between a physician’s rights of self-expression and the external environment (ie, hospital, medical school, patients, society) exist. Perfume or cologne can be physically harmful to patients,17 and piercings and tattoos can be perceived as being offensive.18 Medical students should ask themselves: Does my attire help or hinder the therapeutic relationship? Is my attire safe for the area I am working in (eg, stilettos in the emergency department)? Does my attire degrade or edify the profession?19 Reflective thinking can help medical students make better choices during their educational journey.20 Moreover, this type of thinking may be difficult for students without information to guide them regarding what colleagues and patients consider to be professional and unprofessional attire. The present study aims to help fill that data gap. 
We did not find any correlation between climate and attire. The University of Tasmania School of Medicine and Touro University California, College of Osteopathic Medicine have similar climates (ie, cool, crisp winters, and mild summers). Bond University School of Medicine and Baylor College of Medicine have very hot, humid summers and mild winters. The hot Texas weather, however, did not deter students from wearing white coats as part of their professional attire. Similarly, the cool weather of Tasmania did not steer students toward including white coats in their professional attire. Furthermore, as shown by the present study, ethics courses, as well as school and hospital policies, have little effect on shaping a medical student’s conception of professional clinical attire. Rather, students look to physicians in the inpatient and outpatient settings and model after what those individuals are wearing (ie, cultural practice). Therefore, physicians must also be reflective on their attire. 
A few limitations in the present study exist. For studies involving e-mail surveys, 2 potential denominators for response rates must be considered: the number of intended recipients and the number of actual recipients. Students may block incoming messages when they are away from school or work, or they may auto-forward their work or school e-mail to other e-mail accounts, which can be blocked by spam filters. We did not test the susceptibility of the study announcement e-mail to be flagged by such filters. 
Sample size calculations determined that 327 student and 234 instructor participants were needed. We easily reached our student target, attaining 411 responses; however, we missed our instructor target, attaining 73 responses. We speculate that some instructors may have been busy with administrative, assessment, and teaching duties and viewed survey research as time consuming and burdensome. Also, instructors who are involved in academic duties that lack patient contact might view the survey topic as irrelevant to them or uninteresting. Failure to attain the sample size target in the instructor cohort means that results from that cohort should be interpreted with caution. Another potential explanation for the lack of response is overload and desensitization to survey solicitation if instructors are receiving surveys on a regular basis. 
Additionally, the present study’s findings do not allow us to make global generalizations about appropriate clinical attire. Specifically, in some countries and communities, unique cultural attire such as saris and thobes are considered professional attire for medical students and physicians. 
Conclusion
The results of the present study provide evidence that ethics courses and dress code policies do little to shape a medical student’s conception of professional clinical attire. Both allopathic and osteopathic medical students were most influenced by their instructor’s attire, which distinguishes the present study from others in the literature. This finding points to valuable next steps, including disseminating the current research to residency and fellowship programs. Compared with allopathic medical students, osteopathic medical students are more cognizant of the need to protect patients from environmental allergens such as perfume or cologne. The present study clearly identifies regional dress code practices that are different in the United States compared with Australia. However, many opinions regarding specific dress practices expressed by students and instructors alike were similar. Because the response rate to our survey was variable, additional studies should be conducted for application of these results on a larger scale. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Dr Bramstedt, Mr Colaco, and Dr Rehfield drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
References
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Table 1.
Demographics of US and Australian Medical Students and Instructors Surveyed About Professional Attire (N=484)
Characteristicsa Response Rate, No. (%)
Students (n=411) Instructors (n=73)
  Study Site
   Bond University School of Medicine 47 (13.6) 13 (18.3)
   University of Tasmania School of Medicine 143 (24.9) 43 (71.7)
   Touro University California, College of Osteopathic Medicine 123 (22.8) 16 (24.6)
   Baylor College of Medicine 98 (13.3) 1 (0.3)
   Overall 411 (18.7) 73 (36.7)b
  Age, y
   20-30 344 (84)
   51-60 30 (41)
     Men 156 (38) 30 (42)
  Highest-Earned Academic Degree
   None 160 (39)c
   Bachelor’s 195 (47)
   MD/DO/MBBS 40 (55)
   PhD 15 (21)
  Experience,d, Y
   1 84 (20)
   2e 100 (24)
   3 79 (19)
   4 105 (26)
   5 42 (10)
   6 1 (0.2)
   0-5 15 (21)
   6-10 22 (30)
   11-15 11 (15)
   16-20 9 (12)
   >20 15 (21)

a Not all participants answered all questions.

b Overall response rate for instructors excludes Baylor College of Medicine because of their substantial lack of participation.

c Bond University School of Medicine and the University of Tasmania School of Medicine have 5-year undergraduate programs. Students may enter the program after high school with no degree required.

d Years in school for students; years in teaching for instructors.

e First-year students at Bond University School of Medicine had progressed to year 2 status at the time the survey was administered.

Table 1.
Demographics of US and Australian Medical Students and Instructors Surveyed About Professional Attire (N=484)
Characteristicsa Response Rate, No. (%)
Students (n=411) Instructors (n=73)
  Study Site
   Bond University School of Medicine 47 (13.6) 13 (18.3)
   University of Tasmania School of Medicine 143 (24.9) 43 (71.7)
   Touro University California, College of Osteopathic Medicine 123 (22.8) 16 (24.6)
   Baylor College of Medicine 98 (13.3) 1 (0.3)
   Overall 411 (18.7) 73 (36.7)b
  Age, y
   20-30 344 (84)
   51-60 30 (41)
     Men 156 (38) 30 (42)
  Highest-Earned Academic Degree
   None 160 (39)c
   Bachelor’s 195 (47)
   MD/DO/MBBS 40 (55)
   PhD 15 (21)
  Experience,d, Y
   1 84 (20)
   2e 100 (24)
   3 79 (19)
   4 105 (26)
   5 42 (10)
   6 1 (0.2)
   0-5 15 (21)
   6-10 22 (30)
   11-15 11 (15)
   16-20 9 (12)
   >20 15 (21)

a Not all participants answered all questions.

b Overall response rate for instructors excludes Baylor College of Medicine because of their substantial lack of participation.

c Bond University School of Medicine and the University of Tasmania School of Medicine have 5-year undergraduate programs. Students may enter the program after high school with no degree required.

d Years in school for students; years in teaching for instructors.

e First-year students at Bond University School of Medicine had progressed to year 2 status at the time the survey was administered.

×
Table 2.
A Comparison of US and Australian Medical Students’ Practice of Wearing White Coatsa
Agreement Statement US Students (n=224)b AUST Students (n=189) P Valuesc
   I am required to wear a white coat per school policy. 187 (83) 2 (1) <.001
   I wear a white coat by personal choice. 28 (13) 1 (<1) <.001
   I do not wear a white coat—it is optional at my school. 8 (4) 11 (6) .35
   I do not wear a white coat—it is not part of my school dress code. 1 (<1) 175 (93) <.001

a Statements pertained to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Three responses were duplicates, but they could not be removed because the data were anonymous.

b A P value less than .05 was determined to be statistically significant using Fisher exact test.

Abbreviation: AUST, Australian.

Table 2.
A Comparison of US and Australian Medical Students’ Practice of Wearing White Coatsa
Agreement Statement US Students (n=224)b AUST Students (n=189) P Valuesc
   I am required to wear a white coat per school policy. 187 (83) 2 (1) <.001
   I wear a white coat by personal choice. 28 (13) 1 (<1) <.001
   I do not wear a white coat—it is optional at my school. 8 (4) 11 (6) .35
   I do not wear a white coat—it is not part of my school dress code. 1 (<1) 175 (93) <.001

a Statements pertained to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Three responses were duplicates, but they could not be removed because the data were anonymous.

b A P value less than .05 was determined to be statistically significant using Fisher exact test.

Abbreviation: AUST, Australian.

×
Table 3.
US and Australian Medical Students' and Instructors’ Perceptions About Professional Attire in Clinical Practicea
Agreement Statement Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Overall Perceptions
   Your concept of what is appropriate professional attire has changed over time. 105 (47) 97 (51) .42 9 (56) 26 (46) .68 35 (49) 202 (49) .96
   It is permissible to have a different standard of dress for a medical student and a practicing physician. 105 (47) 84 (44) .69 13 (81) 19 (34) <.001b 32 (44) 189 (46) .94
  Professional Attire
   White coat should be routine attire. 130 (58) 24 (13) <.001b 14 (88) 20 (36) <.001b 34 (47) 154 (38) .16
   White coat should be optional. 78 (35) 52 (28) .15 1 (6) 12 (21) .27 13 (18) 130 (32) .03b
   White coat should not be worn. 15 (7) 111 (59) <.001b 1 (6) 24 (43) .007c 25 (35) 126 (31) .59
   Surgical scrubs are suitable in lieu of other attire. 171 (77) 132 (70) .15 9 (56) 39 (70) .37 48 (67) 303 (74) .27
   Excluding the operating theater, it is appropriate for the clinical setting to affect the choice of professional attire. 209 (94) 165 (88) .08 16 (94) 45 (80) .33 61 (84) 374 (91) .04b
   Neckties should be worn by all male medical students. 29 (13) 6 (3) <.001b 3 (18) 4 (7) .34 7 (10) 35 (9) .92
   Neckties should be prohibited for medical students. 26 (16) 64 (34) <.001b 3 (18) 16 (29) .53 19 (26) 100 (24) .83
   Dress code policies should permit full facial coverage due to religious or cultural beliefs or customs. 145 (66) 91 (48) <.001b 9 (53) 16 (29) .08 25 (34) 236 (58) <.001b
  Perfume or Cologne, Piercings, and Tattoos
   Dress code policies should prohibit perfume and cologne. 36 (16) 6 (3) <.001b 6 (35) 3 (5) .004c 9 (12) 40 (10) .64
   Dress code policies should indicate the avoidance of perfume and cologne. 133 (59) 65 (35) <.001b 9 (53) 27 (48) .95 36 (49) 198 (48) .94
   Dress code policies should not address perfume and cologne. 55 (25) 117 (62) <.001b 2 (12) 26 (46) .01c 28 (38) 172 (42) .003b
   Earrings should be allowed. 175 (80) 167 (88) .03b 12 (75) 43 (80) .73 55 (79) 342 (83) .41
   Nose rings should be allowed. 75 (34) 63 (33) .93 4 (25) 6 (11) .22 10 (14) 138 (34) .002b
   Facial piercings (eg, eyebrow) should be allowed. 28 (13) 28 (15) .66 4 (25) 5 (9) .19 9 (13) 56 (14) .86
   Lip piercings should be allowed. 23 (10) 21 (11) .97 2 (13) 2 (4) .22 4 (6) 44 (11) .28
   Tongue piercings should be allowed. 24 (11) 28 (15) .31 2 (13) 2 (4) .22 4 (6) 52 (13) .11
   Dress code policy should not address piercings. 55 (25) 32 (17) .06 3 (19) 14 (26) .74 17 (24) 87 (21) .68
   Visible tattoos must always be covered. 79 (35) 81 (43) .15 5 (29) 25 (45) .40 30 (41) 160 (39) .79
   Visible tattoos must be covered only if they depict violence, obscenity, or pornography. 122 (55) 96 (51) .36 9 (53) 27(48) .95 36 (49) 218 (53) .69
   Visible tattoos do not require covering. 23 (10) 13 (7) .003b 3 (18) 4 (7) .34 7 (10) 36 (9) .68

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using 2-tailed χ2 (df=1).

c Statistically significant using Fisher exact test (P<.05).

d Only eyes visible.

Abbreviation: AUST, Australian.

Table 3.
US and Australian Medical Students' and Instructors’ Perceptions About Professional Attire in Clinical Practicea
Agreement Statement Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Overall Perceptions
   Your concept of what is appropriate professional attire has changed over time. 105 (47) 97 (51) .42 9 (56) 26 (46) .68 35 (49) 202 (49) .96
   It is permissible to have a different standard of dress for a medical student and a practicing physician. 105 (47) 84 (44) .69 13 (81) 19 (34) <.001b 32 (44) 189 (46) .94
  Professional Attire
   White coat should be routine attire. 130 (58) 24 (13) <.001b 14 (88) 20 (36) <.001b 34 (47) 154 (38) .16
   White coat should be optional. 78 (35) 52 (28) .15 1 (6) 12 (21) .27 13 (18) 130 (32) .03b
   White coat should not be worn. 15 (7) 111 (59) <.001b 1 (6) 24 (43) .007c 25 (35) 126 (31) .59
   Surgical scrubs are suitable in lieu of other attire. 171 (77) 132 (70) .15 9 (56) 39 (70) .37 48 (67) 303 (74) .27
   Excluding the operating theater, it is appropriate for the clinical setting to affect the choice of professional attire. 209 (94) 165 (88) .08 16 (94) 45 (80) .33 61 (84) 374 (91) .04b
   Neckties should be worn by all male medical students. 29 (13) 6 (3) <.001b 3 (18) 4 (7) .34 7 (10) 35 (9) .92
   Neckties should be prohibited for medical students. 26 (16) 64 (34) <.001b 3 (18) 16 (29) .53 19 (26) 100 (24) .83
   Dress code policies should permit full facial coverage due to religious or cultural beliefs or customs. 145 (66) 91 (48) <.001b 9 (53) 16 (29) .08 25 (34) 236 (58) <.001b
  Perfume or Cologne, Piercings, and Tattoos
   Dress code policies should prohibit perfume and cologne. 36 (16) 6 (3) <.001b 6 (35) 3 (5) .004c 9 (12) 40 (10) .64
   Dress code policies should indicate the avoidance of perfume and cologne. 133 (59) 65 (35) <.001b 9 (53) 27 (48) .95 36 (49) 198 (48) .94
   Dress code policies should not address perfume and cologne. 55 (25) 117 (62) <.001b 2 (12) 26 (46) .01c 28 (38) 172 (42) .003b
   Earrings should be allowed. 175 (80) 167 (88) .03b 12 (75) 43 (80) .73 55 (79) 342 (83) .41
   Nose rings should be allowed. 75 (34) 63 (33) .93 4 (25) 6 (11) .22 10 (14) 138 (34) .002b
   Facial piercings (eg, eyebrow) should be allowed. 28 (13) 28 (15) .66 4 (25) 5 (9) .19 9 (13) 56 (14) .86
   Lip piercings should be allowed. 23 (10) 21 (11) .97 2 (13) 2 (4) .22 4 (6) 44 (11) .28
   Tongue piercings should be allowed. 24 (11) 28 (15) .31 2 (13) 2 (4) .22 4 (6) 52 (13) .11
   Dress code policy should not address piercings. 55 (25) 32 (17) .06 3 (19) 14 (26) .74 17 (24) 87 (21) .68
   Visible tattoos must always be covered. 79 (35) 81 (43) .15 5 (29) 25 (45) .40 30 (41) 160 (39) .79
   Visible tattoos must be covered only if they depict violence, obscenity, or pornography. 122 (55) 96 (51) .36 9 (53) 27(48) .95 36 (49) 218 (53) .69
   Visible tattoos do not require covering. 23 (10) 13 (7) .003b 3 (18) 4 (7) .34 7 (10) 36 (9) .68

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using 2-tailed χ2 (df=1).

c Statistically significant using Fisher exact test (P<.05).

d Only eyes visible.

Abbreviation: AUST, Australian.

×
Table 4.
US and Australian Medical Students' and Instructors’ Perceptions About Footwear Restrictions
Type of Footwear Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Sneakers 51 (23) 85 (45) <.001b 5 (29) 26 (46) .34 31 (43) 136 (33) .16
  Running shoesa 111 (50) 136 (73) <.001b 9 (60) 34 (61) .96 43 (61) 247 (61) .96
  Stilettos 78 (35) 115 (61) <.001b 8 (47) 34 (61) .47 42 (58) 193 (47) .13
  Stilettosa 127 (57) 156 (83) <.001b 12 (75) 48 (86) .45 60 (83) 283 (69) .02b
  Open-toed shoes 141 (64) 122 (64) .93 12 (71) 29 (52) .28 41 (56) 263 (64) .24
  Women's no heel, closed toe 59 (27) 59 (31) .35 3 (19) 11 (20) 1.0 14 (20) 118 (29) .15
  Women's low heel, closed toe 13 (6) 13 (7) .80 2 (13) 4 (7) .61 6 (8) 26 (6) .68
  Women's mid heel, closed toe 15 (7) 54 (29) <.001b 1 (6) 12 (21) .27 13 (18) 69 (17) .92
  Boots 18 (8) 23 (12) .24 1 (6) 5 (9) 1.0 6 (8) 41 (19) .80
  Hiking bootsa 104 (47) 102 (54) .15 7 (44) 14 (25) .25 21 (29) 206 (50) .002b
  Ugg bootsa 190 (85) 181 (96) <.001b 12 (75) 51 (91) .10 63(88) 371 (90) .70
  Cowboy bootsa 91 (41) 137 (73) <.001b 8 (50) 26 (46) .80 34 (47) 228 (55) .25
  Sandals 153 (70) 130 (68) .89 11 (65) 31 (55) .69 42 (58) 283 (69) .07
  Sandalsa 203 (91) 179 (95) .17 15 (94) 49 (88) .67 64 (89) 382 (92) .42
  Thong sandals 193 (88) 175 (92) .20 14 (82) 51 (91) .57 65 (89) 368 (90) .85
  Clogsa 67 (30) 137 (73) <.001b 4 (25) 28 (50) .09 32 (44) 204 (50) .51
  Men's Oxford dress shoesa 4 (2) 7 (4) .36 1 (6) 2 (4) .54 3 (4) 11 (3) .44
  Men's boat shoesa 40 (18) 53 (28) .02b 3 (19) 9 (16) .72 12 (17) 93 (23) .34

a Medical students and instructors were shown an image of this footwear.

b Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian.

Table 4.
US and Australian Medical Students' and Instructors’ Perceptions About Footwear Restrictions
Type of Footwear Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Sneakers 51 (23) 85 (45) <.001b 5 (29) 26 (46) .34 31 (43) 136 (33) .16
  Running shoesa 111 (50) 136 (73) <.001b 9 (60) 34 (61) .96 43 (61) 247 (61) .96
  Stilettos 78 (35) 115 (61) <.001b 8 (47) 34 (61) .47 42 (58) 193 (47) .13
  Stilettosa 127 (57) 156 (83) <.001b 12 (75) 48 (86) .45 60 (83) 283 (69) .02b
  Open-toed shoes 141 (64) 122 (64) .93 12 (71) 29 (52) .28 41 (56) 263 (64) .24
  Women's no heel, closed toe 59 (27) 59 (31) .35 3 (19) 11 (20) 1.0 14 (20) 118 (29) .15
  Women's low heel, closed toe 13 (6) 13 (7) .80 2 (13) 4 (7) .61 6 (8) 26 (6) .68
  Women's mid heel, closed toe 15 (7) 54 (29) <.001b 1 (6) 12 (21) .27 13 (18) 69 (17) .92
  Boots 18 (8) 23 (12) .24 1 (6) 5 (9) 1.0 6 (8) 41 (19) .80
  Hiking bootsa 104 (47) 102 (54) .15 7 (44) 14 (25) .25 21 (29) 206 (50) .002b
  Ugg bootsa 190 (85) 181 (96) <.001b 12 (75) 51 (91) .10 63(88) 371 (90) .70
  Cowboy bootsa 91 (41) 137 (73) <.001b 8 (50) 26 (46) .80 34 (47) 228 (55) .25
  Sandals 153 (70) 130 (68) .89 11 (65) 31 (55) .69 42 (58) 283 (69) .07
  Sandalsa 203 (91) 179 (95) .17 15 (94) 49 (88) .67 64 (89) 382 (92) .42
  Thong sandals 193 (88) 175 (92) .20 14 (82) 51 (91) .57 65 (89) 368 (90) .85
  Clogsa 67 (30) 137 (73) <.001b 4 (25) 28 (50) .09 32 (44) 204 (50) .51
  Men's Oxford dress shoesa 4 (2) 7 (4) .36 1 (6) 2 (4) .54 3 (4) 11 (3) .44
  Men's boat shoesa 40 (18) 53 (28) .02b 3 (19) 9 (16) .72 12 (17) 93 (23) .34

a Medical students and instructors were shown an image of this footwear.

b Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian.

×
Table 5.
US and Australian Medical Students' and Instructors' Perceptions About Inappropriate Professional Attire in Clinical Practicea
Attire Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Men's Attire
   Business suit with necktie 101 (46) 113 (60) .01c 8 (50) 30 (54) .80 38 (53) 214 (53) .98
   Slacks and long-sleeve dress shirt, no necktie 31 (14) 5 (3) <.001c 4 (29) 2 (4) .01b 6 (9) 36 (9) .96
   Slacks and long-sleeve dress shirt, with necktie 9 (4) 39 (21) <.001c 2 (13) 12 (22) .72 14 (20) 48 (12) .08
   Slacks and untucked dress shirt 193 (86) 167 (88) .60 13 (87) 38 (68) .20 51 (72) 360 (87) .002c
   Jeans, blazer, dress shirt, no necktie 164 (73) 115 (61) .01c 14 (88) 30 (54) .02b 44 (61) 279 (67) .36
   Jeans, dress shirt, no necktie, no blazer 194 (87) 142 (76) .003c 15 (94) 39 (70) .06 54 (75) 336 (82) .22
   Chino pants, polo shirt 98 (44) 125 (66) <.001c 7 (44) 14 (25) .25 21 (29) 223 (54) <.001c
   Casual pants, T-shirt 204 (92) 175 (94) .64 15 (94) 48 (86) .67 63 (88) 379 (93) .21
   Chino pants, denim shirt 116 (52) 88 (47) .34 12 (75) 13 (23) <.001b 25 (35) 204 (50) .03c
  Women's Attire
   Dress (low neckline) 200 (90) 178 (95) .12 15 (94) 51 (91) <.99 66 (92) 378 (92) .88
   Minidress 184 (83) 143 (76) .09 13 (81) 42 (76) <.99 55 (75) 327 (80) .81
   Business suit 30 (13) 28 (15) .77 3 (19) 3 (5) .12 6 (8) 58 (14) .25
   Jeans, blazer, casual top 157 (70) 105 (56) .003c 14 (93) 21 (38) <.001b 35 (49) 262 (64) .03c
   Jeans, dress shirt 186 (83) 133 (71) .38 14 (88) 32 (57) .04b 46 (64) 319 (77) .02c
   Dress slacks, untucked blouse 59 (26) 60 (32) .27 6 (38) 17 (30) .81 23 (32) 119 (29) .71
   Casual pants, casual untucked shirt 63 (29) 51 (27) .86 5 (31) 7 (13) .17 12 (17) 114 (28) .08
   Skirt, tucked blouse 11 (5) 9 (5) .94 2 (13) 2 (4) .22 4 (6) 20 (5) .77
   Churidar kameez with flip flops sandals (Indian tight trousers with tunic) 163 (73) 134 (71) .76 11 (69) 30 (54) .43 41 (57) 297 (72) .02c

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using Fisher exact test (P<.05).

c Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian

Table 5.
US and Australian Medical Students' and Instructors' Perceptions About Inappropriate Professional Attire in Clinical Practicea
Attire Students (n=411) Instructors (n=73) Overall (Students and Instructors) (N=484)
US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value US, No. (%) AUST, No. (%) P Value
  Men's Attire
   Business suit with necktie 101 (46) 113 (60) .01c 8 (50) 30 (54) .80 38 (53) 214 (53) .98
   Slacks and long-sleeve dress shirt, no necktie 31 (14) 5 (3) <.001c 4 (29) 2 (4) .01b 6 (9) 36 (9) .96
   Slacks and long-sleeve dress shirt, with necktie 9 (4) 39 (21) <.001c 2 (13) 12 (22) .72 14 (20) 48 (12) .08
   Slacks and untucked dress shirt 193 (86) 167 (88) .60 13 (87) 38 (68) .20 51 (72) 360 (87) .002c
   Jeans, blazer, dress shirt, no necktie 164 (73) 115 (61) .01c 14 (88) 30 (54) .02b 44 (61) 279 (67) .36
   Jeans, dress shirt, no necktie, no blazer 194 (87) 142 (76) .003c 15 (94) 39 (70) .06 54 (75) 336 (82) .22
   Chino pants, polo shirt 98 (44) 125 (66) <.001c 7 (44) 14 (25) .25 21 (29) 223 (54) <.001c
   Casual pants, T-shirt 204 (92) 175 (94) .64 15 (94) 48 (86) .67 63 (88) 379 (93) .21
   Chino pants, denim shirt 116 (52) 88 (47) .34 12 (75) 13 (23) <.001b 25 (35) 204 (50) .03c
  Women's Attire
   Dress (low neckline) 200 (90) 178 (95) .12 15 (94) 51 (91) <.99 66 (92) 378 (92) .88
   Minidress 184 (83) 143 (76) .09 13 (81) 42 (76) <.99 55 (75) 327 (80) .81
   Business suit 30 (13) 28 (15) .77 3 (19) 3 (5) .12 6 (8) 58 (14) .25
   Jeans, blazer, casual top 157 (70) 105 (56) .003c 14 (93) 21 (38) <.001b 35 (49) 262 (64) .03c
   Jeans, dress shirt 186 (83) 133 (71) .38 14 (88) 32 (57) .04b 46 (64) 319 (77) .02c
   Dress slacks, untucked blouse 59 (26) 60 (32) .27 6 (38) 17 (30) .81 23 (32) 119 (29) .71
   Casual pants, casual untucked shirt 63 (29) 51 (27) .86 5 (31) 7 (13) .17 12 (17) 114 (28) .08
   Skirt, tucked blouse 11 (5) 9 (5) .94 2 (13) 2 (4) .22 4 (6) 20 (5) .77
   Churidar kameez with flip flops sandals (Indian tight trousers with tunic) 163 (73) 134 (71) .76 11 (69) 30 (54) .43 41 (57) 297 (72) .02c

a Clinical practice refers to inpatient or outpatient settings, as well as educational sessions with standardized patients.

b Statistically significant using Fisher exact test (P<.05).

c Statistically significant using 2-tailed χ2 (df=1).

Abbreviation: AUST, Australian

×