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Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study

Importance of physicians’ attire: factors influencing the impression it makes on patients, a... Objective: The aim of the present study was to determine the importance of physician attire in inspiring confidence in patients, patient preferences and factors influencing the impression made by the clothing worn by doctors. Methods: Self-administered questionnaires were distributed and completed in five pharmacies across Japan (April–October 2012) to patients or their carers (aged ≥20 years). The survey was performed over 2 consecutive days in each pharmacy. To estimate patient confidence in doctors, questions were asked addressing six items, namely doctors’ attire, speech (way of speaking, volume, tone etc.), age, gender, title (professor, PhD etc.) and reputation. Participants were shown photographs of five different types of attire for male and female doctors (i.e. white coats, scrubs, semiformal, smart casual and casual wear) and asked to rate the appropriateness of each clothing style using a five-point Likert scale. Results: Of the 1411 patients or carers who attended the pharmacies, 530 responded to the questionnaire, with 491 complete responses used in subsequent analyses. The mean age of respondents was 51.9 years and 40.3% were male. Speech was the most important factor (mean score 4.60) in determining confidence in doctors, followed by reputation (4.06) and attire (4.00). With regard to attire, regardless of a doctor’s gender, the white coat was judged to be the most appropriate style of dress, followed by surgical scrubs. Only the preference for scrubs was significantly affected by age, gender and region (P < 0.05). Using binomial logistic regression analysis, we evaluated the effects of age on theappropriateness (Likertscore 3–5) versus inappropriateness (score 1–2) of scrubs. There was a significant increase in the number of subjects aged 50–64 and >65 years of age who thought scrubs were inappropriate compared with those aged 20–34 years (adjusted odds ratios of 4.30 and 12.7 for male doctors, and 3.66 and 6.91 for female doctors). Conclusions: Attire is one of the important factor that inspires patient confidence in physicians. White coats were deemed the most appropriate clothing style for doctors, followed by scrubs. However, older participants perceived scrubs to be less appropriate attire than younger subjects. Keywords: Doctor-patient relationship, Confidence in doctors, Patients’ preferences, White coat, Scrubs, Doctor’s attire, Communication Background approximately 70% of their study participants considered The patient–doctor relationship is considered the corner- that physicians’ attire influenced their confidence in the stone of medical care. Physician attire is not only a way physicians [1]. However, others have reported that patient of protecting oneself from microscopic organisms, but satisfaction is unaffected by the way in which doctors is also a symbol of competence and status. Previous dress [2,3]. Other factors, such as age, gender and the studies have shown that patients regard the way in which way in which physicians speak, have been reported as physicians dress as important. Yamada et al. reported that influencing patient trust [4,5]. However, few studies have investigated the importance of doctors’ attire relative to * Correspondence: hkurihara-tkb@umin.ac.jp other factors inspiring confidence. Department of General Medicine and Primary Care, University of Tsukuba Hospital, Amakubo 2-1-1, Tsukuba City, Ibaraki Prefecture 305-0005, Japan © 2014 Kurihara et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 2 of 7 http://www.apfmj.com/content/13/1/2 Physicians once only wore white coats, but recently questionnaire or were too ill to answer the questions their dress has become more varied. Along with tra- were excluded from the study. ditional long-sleeved white coats, doctors now appear more casually dressed. Some studies report that patients Survey period tend to prefer that doctors wear white coats [1,6-8], The survey was performed over 2 consecutive days in whereas others have reported that patients do not mind each pharmacy in the period April–October 2012. what doctors wear [9,10] or prefer that they wear semi- formal or formal clothing rather than white coats Questionnaire [11,12]. Because most previous studies have been con- To develop the questionnaire, we reviewed previous ducted in a single hospital or clinic [1,6-9,12], the results studies, discussed them among the researchers, and mayreflect the culture of a specificsetting andits influence then decided on the questionnaire items. For factors on patients. The contribution of other factors (patients’ age, that might influence the doctor’s confidence, we chose gender, area) on the impression created by what doctors items reported in previous studies as important [1,4,5,13]. wear is not evident. Finally we investigated six items, namely attire, speech Demonstrating the importance of physician attire and (way of speaking, volume, pitch etc.), age, gender, title the factors that may influence patient responses will allow (professor, PhD etc.) and the doctor’sreputation. Regar- doctors to pay more attention to their clothing to foster ding to reputation, we would like to explore the impact of good patient–doctor relationships. Preferences regarding doctor’s impression from people around such as doctor’s physician attire will change with time, and so newer infor- character, communication style and skills. Participants mation is currently needed. The aim of the present study were asked to rank the importance of each factor on a was to address the following three questions: five-point Likert scale, from 1 (not important at all) to 5 (very important). 1. Compared with other factors, how important is For the doctor’s attire, according to previous studies, we physician attire in contributing to patient confidence? chose five clothing styles (white coat, scrubs, semiformal, 2. What types of physician attire do patients prefer? smart casual and casual dress) and showed them to the 3. What factors influence patients’ impressions of participants by photographs [1,9,12]. Participants were physicians’ attire? shown two sets of five photographs (Figure 1), one set showing clothing styles for male doctors and the other Methods showing styles for female doctors. Briefly, the “white Study design coat” style consisted of a shirt, necktie and white coat The present cross-sectional study used self-administered for men, and a skirt and white coat for women; the questionnaires. The study was approved by the Ethics scrubs consisted of dark red scrubs for both men and Committee of the Faculty of Medicine of the University women; semiformal clothing consisted of a shirt and of Tsukuba. necktie for men, and a blouse and skirt for women; smart casual clothing was a white polo shirt for men, and Study setting sleeveless blouse and skirt for women; and casual clothing The survey was conducted at five pharmacies in three consisted of jeans and a T-shirt for men, and a T-shirt regions in Japan, namely Ibaraki Prefecture (Region 1; with skirt for women.In all photographs, the background, two pharmacies), Niigata Prefecture (Region 2; two phar- camera angle, posture, position of the stethoscope and macies) and Tokyo (Region 3; one pharmacy). There name tag were kept constant. To avoid potential effects of were two reasons why we chose pharmacies. First, they expression and countenance, no faces appeared in any allowed for a wider sample, because patients could be of the photographs. These photographs were presented recruited in the one pharmacy who consulted more to participants on a tablet. Participants were asked to than one hospital or clinic. Second, by recruiting patients indicate the appropriateness of the attire using a five-point in pharmacies, we thought they would be able to answer Likert scale, from 1 (absolutely disagree) to 5 (absolutely the questionnaire without worrying about surveillance agree). from medical personnel. Finally, background information regarding the age and gender of the respondents was collected. Participants Patients or their carers (≥20 years of age at the time of Statistical analysis the study) attending the pharmacies were recruited as Each of the items evaluated using the five-point Likert study participants. Written informed consent was obtained scale was given an overall score from 1 (“not important” from the participants prior to taking the questionnaire. at all or “absolutely disagree”)to5(“very important” or Patients or their carers who declined complete the “absolutely agree”). As in a previous study [14], we divided Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 3 of 7 http://www.apfmj.com/content/13/1/2 Figure 1 Photographs shown to study participants of the different clothing styles for male and female doctors. The “white coat” style consisted of a shirt, necktie and white coat for men, and a skirt and white coat for women; the scrubs consisted of dark red scrubs for both men and women; semiformal clothing consisted of a shirt and necktie for men, and a blouse and skirt for women; smart casual clothing was a white polo shirt for men, and a sleeveless blouse and skirt for women; casual clothing consisted of jeans and a T-shirt for men, and a T-shirt with skirt for women. In all photographs, the background, camera angle, posture, position of the stethoscope and name tag were kept constant, and, to avoid any effects of expression and countenance, no faces appeared in any of the photographs. the participants into four, 15-year age-range groups: binomial logistic regression analysis. The independent (i) <35 years of age (younger group); (ii) from 35 to 49 variables were gender, age group and region. The refe- years of age (lower-middle group); (iii) from 50 to 64 rence groups for the individual factors were male gender, years of age (higher-middle group); and (iv) >65 years age <35 years (younger group) and Region 1. Odds ratios of age(elderlygroup). (OR) and 95% confidence intervals (CI) were calculated Data were analysed as follows. First, to analyse the factors to estimate the association between inappropriateness influencing confidence in doctors, the mean score was and the different factors. calculated for each item. Then, univariate analysis was Where appropriate, Likert scores for the different items used to analyse the factors associated with preferences for are given as the mean ± SD. All analyses were conducted each style. A t-test was used to determine the effects of using SPSS, version 21.0 J. In all analyses, P <0.05 was gender on factors affecting preferences, whereas analysis considered significant. of variance (ANOVA) was used to investigate the effects of age and region in Japan. A multivariate model was used to determine what was Results considered inappropriate physician attire. In this ana- In all, 1411 patients or their carers attended one of the lysis, clothing styles were divided into an “inappropriate” pharmacies, with 530 patients or their carers agreeing to group (= 1) based on Likert scores of 1–2 and into an participate in the study (37.6% response rate). Of the 530 “appropriate” group (= 0) based on scores of 3–5, with people who agreed to participate in the study, complete these groups being defined as the dependent variables in survey responses were available for 491 and these were Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 4 of 7 http://www.apfmj.com/content/13/1/2 Table 1 Participant characteristics (n = 491) No. % men Mean (±SD) No. participants in different age groups participants age (years) 20–34 years 35–49 years 50–64 years 65+ years Region 1 192 43.2 51.7 ± 15.9 35 49 63 45 Region 2 189 40.7 56.6 ± 14.4 16 32 86 55 Region 3 110 34.5 44.3 ± 13.3 31 41 31 7 Total 491 40.3 51.9 ± 15.6 82 122 180 107 The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). subsequently used in the analyses. The characteristics of considered to be the most appropriate clothing style for the study participants are listed in Table 1. both male and female doctors, followed by scrubs and Figure 2 shows the influence of the six items evalu- smart casual clothing for men and scrubs alone for women. ated in the present study on patient confidence in Table 2 also lists mean scores for the each of the five doctors. Speech (mean [±SD] score 4.60 ± 0.68), reputa- clothing styles according to age group. Participants tion (4.06 ± 0.93) and attire (4.00 ± 0.94) were considered ranked the white coat style as the best for doctors of important by patients. Less crucial factors were doctors’ both genders. For some attire, the mean scores for the titles (3.04 ± 1.01), age (3.01 ± 1.04) and gender (2.73 ± 1.01). different clothing styles varied among the different age White coats were considered to be the most appropriate groups. Significant differences were found for the ranking style of clothing, following by scrubs, for both male and of scrubs (P < 0.01) and casual attire (P < 0.01) for male emale physicians. The other clothing styles (i.e. semi- doctors, and for scrubs for female doctors (P < 0.01). formal, smart casual and causal) were given lower scores. Elderly people considered scrubs less appropriate for Only 5.3% and 1.0% of participants thought that white both male and female doctors. Regardless of physician coats were inappropriate (score of 1 or 2) for male and gender, scrubs were rated significantly more highly by female doctors, respectively. A similar proportion of female participants, whereas male participants ranked participants thought scrubs were inappropriate for the smart casual style more highly for female doctors. male and female doctors (15.5% vs 15.1%, respectively). Significant differences according to age group, region However, a higher proportion of participants thought and gender were evident only for scrubs. A multivariate that semiformal, smart casual and casual dress was model was fitted to the factors, with Table 3 listing the inappropriate for both male (48.5%, 23.8% and 73.3%, OR for the inappropriateness of scrubs according to each respectively) and female (37.1%, 73.1% and 79.8%, respec- factor after adjustment for all others. The main finding tively) physicians. is a significant increase in the inappropriateness of There were significant differences only in mean scores scrubs according to participants aged 50–64 and >65 years for scrubs as a clothing style among the three regions compared with the younger group, with an adjusted OR (Table 2). In each of the three regions, white coats were of 4.30 (95% CI 1.24–14.90) and 12.7 (95% CI 3.64–44.8) for male doctors, respectively, and 3.66 (95% CI 1.22– 11.0) and 6.91 (95% CI 2.24–21.33) for female doctors, respectively. There was also a significant difference among regions in the appropriateness of scrubs, with a significant increase in appropriateness reported for female doctors in Region 2 compared with Region 1 (adjusted OR of 1.98; 95% CI 1.10–3.58). Discussion In terms of inspiring confidence and trust, participants rated a doctor’s speech, reputation and attire as quite important, but age, title and gender less so. However, each factor may make an important contribution to a Figure 2 Effects of six items on patient confidence in doctors. patient’s judgment of his/her doctor. Shah and Ogden Results show the mean scores on a five-point Likert scale for the reported that patients consider age and gender to be importance of speech, reputation, attire, age, title and gender on important because these factors relate to personal manners, patient confidence in doctors. as well as technical and explanatory skills [4]. In another Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 5 of 7 http://www.apfmj.com/content/13/1/2 Table 2 Evaluation of the appropriateness of different types of attire according to region in Japan and age group Region in Japan Age group (years) Region 1 Region 2 Region 3 P-value 20–34 35–49 50–64 65+ P-value Male physicians White coat 4.17 ± 0.94 4.10 ± 0.93 4.25 ± 0.89 0.38 4.32 ± 0.77 4.18 ± 0.86 4.04 ± 0.94 4.22 ± 1.06 0.12 Scrubs 3.66 ± 1.04 3.35 ± 1.10 3.58 ± 0.96 0.01 3.90 ± 0.86 3.75 ± 0.89 3.46 ± 1.04 3.08 ± 1.21 <0.01 Semiformal 2.58 ± 0.96 2.56 ± 1.05 2.66 ± 0.94 0.68 2.67 ± 0.90 2.57 ± 0.94 2.48 ± 0.96 2.74 ± 1.14 0.17 Smart casual 3.24 ± 1.12 3.22 ± 1.13 3.51 ± 1.01 0.07 3.35 ± 1.16 3.22 ± 1.01 3.18 ± 1.08 3.53 ± 1.18 0.50 Casual 1.96 ± 0.84 2.08 ± 1.00 1.89 ± 0.87 0.17 1.85 ± 0.79 1.87 ± 0.79 1.97 ± 0.92 2.28 ± 1.06 0.02 Female physicians White coat 4.38 ± 0.81 4.28 ± 0.78 4.32 ± 0.81 0.51 4.51 ± 0.65 4.30 ± 0.77 4.25 ± 0.80 4.35 ± 0.90 0.10 Scrubs 3.79 ± 1.04 3.35 ± 1.06 3.69 ± 0.99 <0.01 3.99 ± 0.84 3.87 ± 0.94 3.49 ± 1.05 3.16 ± 1.14 <0.01 Semiformal 2.89 ± 1.01 2.76 ± 1.01 2.94 ± 1.05 0.29 3.01 ± 0.95 2.80 ± 0.90 2.73 ± 1.01 2.98 ± 1.13 0.08 Smart casual 2.09 ± 0.92 2.02 ± 0.96 2.11 ± 0.92 0.68 2.15 ± 0.86 2.02 ± 0.87 1.98 ± 0.88 2.21 ± 1.12 0.19 Casual 1.93 ± 0.87 1.90 ± 0.93 1.82 ± 0.87 0.55 1.80 ± 0.79 1.86 ± 0.81 1.86 ± 0.84 2.06 ± 1.04 0.17 Data show the mean ± SD scores after participants had been asked to indicate the appropriateness of the attire shown in Figure 1 using a five-point Likert scale, ranging from 1 (absolutely disagree) to 5 (absolutely agree). The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). Analysis of variance (ANOVA) was used for univariate analysis. study, the tone of voice was significantly associated with to other factors. The importance of attire is not inferior, malpractice claim history [5], whereas Torres et al. found but actually rather high. that a physician’s reputation is positively associated Our finding that patients tend to prefer that doctors with patient trust and satisfaction [13]. Many studies wear white coats is similar to that reported by many have investigated factors affecting patient faith in doctors. other studies worldwide [1,6,7,15-19]. Despite differences However, few studies have been comparative. In the between countries, the white coat is a symbol of doctors, present study, we show the importance of attire in relation and it may create a sense of ease or confidence in patients. Table 3 Association between subject characteristics and the perceived “inappropriateness” of scrubs as clothing for male and female doctors Factor Male doctors Female doctors OR (95% CI) P-value OR (95% CI) P-value Gender Male 1.00 1.00 Female 0.77 (0.45–1.30) 0.33 0.67 (0.40–1.14) 0.14 Area in Japan Region 1 1.00 1.00 Region 2 1.78 (0.99–3.21) 0.05 1.98 (1.10–3.58) 0.02 Region 3 1.54 (0.69–3.41) 0.29 1.56 (0.70–3.47) 0.27 Age group (years) 20–34 1.00 1.00 35–49 2.11 (0.55–8.07) 0.28 1.38 (0.40–4.77) 0.61 50–64 4.30 (1.24–14.90) 0.02 3.66 (1.22–10.98) 0.02 65+ 12.77 (3.64–44.76) <0.01 6.91 (2.24–21.33) <0.01 The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). In this analysis, scrub styles were divided into an “inappropriate” group (= 1) based on Likert scores of 1–2 and into an “appropriate” group (= 0) based on scores of 3–5, with these groups being defined as the dependent variables in binomial logistic regression analysis. The independent variables were gender, age group and region. The reference groups for the individual factors were male gender, age <35 years (younger group) and Region 1. OR odds ratio, CI confidence interval. Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 6 of 7 http://www.apfmj.com/content/13/1/2 In the present study, only 5% of participants regarded to them, with different colours perhaps eliciting different the white coat as inappropriate. Considering that physician reactions. So, using only one colour for the scrubs is also a attire is important to patients, white coats are an appropri- limitation of the study. Patients, especially elderly patients, ate clothing style for doctors. may have found it odd that doctors were not wearing In the present study, almost 40% of participants consi- white clothing, although scrub colours vary. Because dered a semiformal style, which is often seen in Japanese younger people have seen colourful scrubs in TV dramas, hospitals, as less appropriate. The preference for this such as “ER”, they may not find the red scrubs incongru- clothing style has varied among studies [1,6,14]. For ous. Thus, it may be necessary to clarify the relationship example, Lill et al. reported that the semiformal was between patient age and their preference for the colour of the favourite style in New Zealand [12], yet Yamada physicians’ attire. et al. found that patients do not like this style of clothing The present study has demonstrated the importance in Japan [1]. The findings of Yamada et al. were echoed of physician attire in patient perceptions. However, the in the present study in other regions in Japan. influence of a particular style of attire may last only a Patients tended to think that scrubs were almost as short time. Thus, it is necessary to clarify whether clothes appropriate as white coats, but the inappropriateness of can influence long-term patient–doctor relationships. scrubs differed according to age and regions. Elderly people regarded scrubs as less appropriate than did Conclusions younger people. The same finding has been reported in We have shown physicians attire after the speech and the UK [6]. Doctors could consider this when attending reputation is one of the most important factor inspiring elderly patients. With regard to the difference between physician confidence in their physicians. We have shown regions, this could reflect different levels of recognition the importance of physicians’ attire in patient perceptions. of scrubs, which are relatively new attire for doctors, Specifically, it is an important factor inspiring physician although identifying such reasons was beyond the scope confidence. White coats were seen as the most appropri- of the study design. ate style for doctors, regardless of gender, followed by In 2007, the British Department of Health published scrubs. However, older study participants perceived scrubs guidelines for good practice regarding uniforms and work as less appropriate attire than younger participants. wear [20]. Because cuffs become heavily contaminated Competing interests and are more likely to come into contact with patients, The authors declare that they have no competing interests. the guidelines recommend wearing short-sleeved shirts or blouses and to avoid wearing white coats when providing Authors’ contributions patient care [20]. Surgical scrubs are more hygienic HK participated in the proposal’s design, coordination, and data collection, carried out the study and drafted and completed the manuscript. Takami M and comfortable for doctors; thus, they may become participated in the proposal’s design, and coordination, and in drafting more common attire in the future. In this case, it may the manuscript. Tetsuhiro M participated in the proposal’s design, and be necessary to inform elderly patients of the medical coordination, and in drafting the manuscript. All authors read and approved the final manuscript. virtues of this type of clothing. Acknowledgement Limitations We would like to thank Mirai INC., Kraft INC. and AIN Pharmacies INC., which There are several limitations to the present study. First, gave us an opportunity for conducting this survey. And we also would like to thank all of the staff of the five pharmacies who supported us in this survey. the response rate was only 35% and so there may be a This work was supported by JSPS KAKENHI Grant Number 24590598. problem with internal validity. However, the results (i.e. white coats and scrubs are the preferred clothing style) are Received: 12 July 2013 Accepted: 6 January 2014 Published: 8 January 2014 similar to those reported in a previous study conducted in Japan [1]. Thus, we think the reliability of the study References is acceptable. 1. Yamada Y, Takahashi O, Ohde S, Deshpande GA, Fukui T: Patients’ Second, we are unsure whether the pharmacies chosen preferences for doctors’ attire in Japan. Intern Med 2010, 49:1521–1526. 2. Druss RG: The magic white coat. Ann Intern Med 1998, 129:743. for subject recruitment accurately represent the regions 3. Hennessy N, Harrison DA, Aitkenhead AR: The effect of the anaesthetist’s in which they are located or even all areas of Japan. Settings attire on patient attitudes. The influence of dress on patient perception (inpatient vs outpatient), cultural differences and physician of the anaesthetist’s prestige. Anaesthesia 1993, 48:219–222. 4. Shah R, Ogden J: ‘What’s in a face?’ The role of doctor ethnicity, age and specialties may limit the applicability of our results regar- gender in the formation of patients’ judgements: an experimental study. ding the preferences for doctors’ attire. However, the survey Patient Educ Couns 2006, 60:136–141. was conducted in three, not just one, regions of Japan to 5. Ambady N, Laplante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W: Surgeons’ tone of voice: a clue to malpractice history. Surgery 2002, 132:5–9. collect a wider sample. 6. Gherardi G, Cameron J, West A, Crossley M: Are we dressed to impress? Third, the colour of the scrubs (dark red) in the present A descriptive survey assessing patients’ preference of doctors’ attire in study may have contributed to the generational reaction the hospital setting. Clin Med 2009, 9:519–524. Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 7 of 7 http://www.apfmj.com/content/13/1/2 7. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO: What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med 2005, 118:1279–1286. 8. Cha A, Hecht BR, Nelson K, Hopkins MP: Resident physician attire: does it make a difference to our patients? Am J Obstet Gynecol 2004, 190:1484–1488. 9. Shelton CL, Raistrick C, Warburton K, Siddiqui KH: Can changes in clinical attire reduce likelihood of cross-infection without jeopardising the doctor-patient relationship? J Hosp Infect 2010, 74:22–29. 10. Boon D, Wardrope J: What should doctors wear in the accident and emergency department? Patients’ perception. J Accid Emerg Med 1994, 11:175–177. 11. McKinstry B, Wang JX: Putting on the style: what patients think of the way their doctor dresses. Br J Gen Pract 1991, 41:270. 275–278. 12. Lill MM, Wilkinson TJ: Judging a book by its cover: descriptive survey of patients’ preferences for doctors’ appearance and mode of address. BMJ 2005, 331:1524–1527. 13. Torres E, Vasquez-Parraga AZ, Barra C: The path of patient loyalty and the role of doctor reputation. Health Market Q 2009, 26:183–197. 14. Hueston WJ, Carek SM: Patients’ preference for physician attire: a survey of patients in family medicine training practices. Fam Med 2011, 43:643–647. 15. Gooden BR, Smith MJ, Tattersall SJ, Stockler MR: Hospitalised patients’ views on doctors and white coats. Med J Aust 2001, 175:219–222. 16. Turner RN, Leach J, Robinson D: First impressions in complementary practice: the importance of environment, dress and address to the therapeutic relationship. Complement Ther Clin Pract 2007, 13:102–109. 17. Rowland PA, Coe NP, Burchard KW, Pricolo VE: Factors affecting the professional image of physicians. Curr Surg 2005, 62:214–219. 18. Douse J, Derrett-Smith E, Dheda K, Dilworth JP: Should doctors wear white coats? Postgrad Med J 2004, 80:284–286. 19. Keenum AJ, Wallace LS, Stevens AR: Patients’ attitudes regarding physical characteristics of family practice physicians. South Med J 2003, 96:1190–1194. 20. Uniforms and workwear:an evidence base for developing local policy. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_078435.pdf. doi:10.1186/1447-056X-13-2 Cite this article as: Kurihara et al.: Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. 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Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study

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Copyright © 2014 by Kurihara et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Objective: The aim of the present study was to determine the importance of physician attire in inspiring confidence in patients, patient preferences and factors influencing the impression made by the clothing worn by doctors. Methods: Self-administered questionnaires were distributed and completed in five pharmacies across Japan (April–October 2012) to patients or their carers (aged ≥20 years). The survey was performed over 2 consecutive days in each pharmacy. To estimate patient confidence in doctors, questions were asked addressing six items, namely doctors’ attire, speech (way of speaking, volume, tone etc.), age, gender, title (professor, PhD etc.) and reputation. Participants were shown photographs of five different types of attire for male and female doctors (i.e. white coats, scrubs, semiformal, smart casual and casual wear) and asked to rate the appropriateness of each clothing style using a five-point Likert scale. Results: Of the 1411 patients or carers who attended the pharmacies, 530 responded to the questionnaire, with 491 complete responses used in subsequent analyses. The mean age of respondents was 51.9 years and 40.3% were male. Speech was the most important factor (mean score 4.60) in determining confidence in doctors, followed by reputation (4.06) and attire (4.00). With regard to attire, regardless of a doctor’s gender, the white coat was judged to be the most appropriate style of dress, followed by surgical scrubs. Only the preference for scrubs was significantly affected by age, gender and region (P < 0.05). Using binomial logistic regression analysis, we evaluated the effects of age on theappropriateness (Likertscore 3–5) versus inappropriateness (score 1–2) of scrubs. There was a significant increase in the number of subjects aged 50–64 and >65 years of age who thought scrubs were inappropriate compared with those aged 20–34 years (adjusted odds ratios of 4.30 and 12.7 for male doctors, and 3.66 and 6.91 for female doctors). Conclusions: Attire is one of the important factor that inspires patient confidence in physicians. White coats were deemed the most appropriate clothing style for doctors, followed by scrubs. However, older participants perceived scrubs to be less appropriate attire than younger subjects. Keywords: Doctor-patient relationship, Confidence in doctors, Patients’ preferences, White coat, Scrubs, Doctor’s attire, Communication Background approximately 70% of their study participants considered The patient–doctor relationship is considered the corner- that physicians’ attire influenced their confidence in the stone of medical care. Physician attire is not only a way physicians [1]. However, others have reported that patient of protecting oneself from microscopic organisms, but satisfaction is unaffected by the way in which doctors is also a symbol of competence and status. Previous dress [2,3]. Other factors, such as age, gender and the studies have shown that patients regard the way in which way in which physicians speak, have been reported as physicians dress as important. Yamada et al. reported that influencing patient trust [4,5]. However, few studies have investigated the importance of doctors’ attire relative to * Correspondence: hkurihara-tkb@umin.ac.jp other factors inspiring confidence. Department of General Medicine and Primary Care, University of Tsukuba Hospital, Amakubo 2-1-1, Tsukuba City, Ibaraki Prefecture 305-0005, Japan © 2014 Kurihara et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 2 of 7 http://www.apfmj.com/content/13/1/2 Physicians once only wore white coats, but recently questionnaire or were too ill to answer the questions their dress has become more varied. Along with tra- were excluded from the study. ditional long-sleeved white coats, doctors now appear more casually dressed. Some studies report that patients Survey period tend to prefer that doctors wear white coats [1,6-8], The survey was performed over 2 consecutive days in whereas others have reported that patients do not mind each pharmacy in the period April–October 2012. what doctors wear [9,10] or prefer that they wear semi- formal or formal clothing rather than white coats Questionnaire [11,12]. Because most previous studies have been con- To develop the questionnaire, we reviewed previous ducted in a single hospital or clinic [1,6-9,12], the results studies, discussed them among the researchers, and mayreflect the culture of a specificsetting andits influence then decided on the questionnaire items. For factors on patients. The contribution of other factors (patients’ age, that might influence the doctor’s confidence, we chose gender, area) on the impression created by what doctors items reported in previous studies as important [1,4,5,13]. wear is not evident. Finally we investigated six items, namely attire, speech Demonstrating the importance of physician attire and (way of speaking, volume, pitch etc.), age, gender, title the factors that may influence patient responses will allow (professor, PhD etc.) and the doctor’sreputation. Regar- doctors to pay more attention to their clothing to foster ding to reputation, we would like to explore the impact of good patient–doctor relationships. Preferences regarding doctor’s impression from people around such as doctor’s physician attire will change with time, and so newer infor- character, communication style and skills. Participants mation is currently needed. The aim of the present study were asked to rank the importance of each factor on a was to address the following three questions: five-point Likert scale, from 1 (not important at all) to 5 (very important). 1. Compared with other factors, how important is For the doctor’s attire, according to previous studies, we physician attire in contributing to patient confidence? chose five clothing styles (white coat, scrubs, semiformal, 2. What types of physician attire do patients prefer? smart casual and casual dress) and showed them to the 3. What factors influence patients’ impressions of participants by photographs [1,9,12]. Participants were physicians’ attire? shown two sets of five photographs (Figure 1), one set showing clothing styles for male doctors and the other Methods showing styles for female doctors. Briefly, the “white Study design coat” style consisted of a shirt, necktie and white coat The present cross-sectional study used self-administered for men, and a skirt and white coat for women; the questionnaires. The study was approved by the Ethics scrubs consisted of dark red scrubs for both men and Committee of the Faculty of Medicine of the University women; semiformal clothing consisted of a shirt and of Tsukuba. necktie for men, and a blouse and skirt for women; smart casual clothing was a white polo shirt for men, and Study setting sleeveless blouse and skirt for women; and casual clothing The survey was conducted at five pharmacies in three consisted of jeans and a T-shirt for men, and a T-shirt regions in Japan, namely Ibaraki Prefecture (Region 1; with skirt for women.In all photographs, the background, two pharmacies), Niigata Prefecture (Region 2; two phar- camera angle, posture, position of the stethoscope and macies) and Tokyo (Region 3; one pharmacy). There name tag were kept constant. To avoid potential effects of were two reasons why we chose pharmacies. First, they expression and countenance, no faces appeared in any allowed for a wider sample, because patients could be of the photographs. These photographs were presented recruited in the one pharmacy who consulted more to participants on a tablet. Participants were asked to than one hospital or clinic. Second, by recruiting patients indicate the appropriateness of the attire using a five-point in pharmacies, we thought they would be able to answer Likert scale, from 1 (absolutely disagree) to 5 (absolutely the questionnaire without worrying about surveillance agree). from medical personnel. Finally, background information regarding the age and gender of the respondents was collected. Participants Patients or their carers (≥20 years of age at the time of Statistical analysis the study) attending the pharmacies were recruited as Each of the items evaluated using the five-point Likert study participants. Written informed consent was obtained scale was given an overall score from 1 (“not important” from the participants prior to taking the questionnaire. at all or “absolutely disagree”)to5(“very important” or Patients or their carers who declined complete the “absolutely agree”). As in a previous study [14], we divided Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 3 of 7 http://www.apfmj.com/content/13/1/2 Figure 1 Photographs shown to study participants of the different clothing styles for male and female doctors. The “white coat” style consisted of a shirt, necktie and white coat for men, and a skirt and white coat for women; the scrubs consisted of dark red scrubs for both men and women; semiformal clothing consisted of a shirt and necktie for men, and a blouse and skirt for women; smart casual clothing was a white polo shirt for men, and a sleeveless blouse and skirt for women; casual clothing consisted of jeans and a T-shirt for men, and a T-shirt with skirt for women. In all photographs, the background, camera angle, posture, position of the stethoscope and name tag were kept constant, and, to avoid any effects of expression and countenance, no faces appeared in any of the photographs. the participants into four, 15-year age-range groups: binomial logistic regression analysis. The independent (i) <35 years of age (younger group); (ii) from 35 to 49 variables were gender, age group and region. The refe- years of age (lower-middle group); (iii) from 50 to 64 rence groups for the individual factors were male gender, years of age (higher-middle group); and (iv) >65 years age <35 years (younger group) and Region 1. Odds ratios of age(elderlygroup). (OR) and 95% confidence intervals (CI) were calculated Data were analysed as follows. First, to analyse the factors to estimate the association between inappropriateness influencing confidence in doctors, the mean score was and the different factors. calculated for each item. Then, univariate analysis was Where appropriate, Likert scores for the different items used to analyse the factors associated with preferences for are given as the mean ± SD. All analyses were conducted each style. A t-test was used to determine the effects of using SPSS, version 21.0 J. In all analyses, P <0.05 was gender on factors affecting preferences, whereas analysis considered significant. of variance (ANOVA) was used to investigate the effects of age and region in Japan. A multivariate model was used to determine what was Results considered inappropriate physician attire. In this ana- In all, 1411 patients or their carers attended one of the lysis, clothing styles were divided into an “inappropriate” pharmacies, with 530 patients or their carers agreeing to group (= 1) based on Likert scores of 1–2 and into an participate in the study (37.6% response rate). Of the 530 “appropriate” group (= 0) based on scores of 3–5, with people who agreed to participate in the study, complete these groups being defined as the dependent variables in survey responses were available for 491 and these were Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 4 of 7 http://www.apfmj.com/content/13/1/2 Table 1 Participant characteristics (n = 491) No. % men Mean (±SD) No. participants in different age groups participants age (years) 20–34 years 35–49 years 50–64 years 65+ years Region 1 192 43.2 51.7 ± 15.9 35 49 63 45 Region 2 189 40.7 56.6 ± 14.4 16 32 86 55 Region 3 110 34.5 44.3 ± 13.3 31 41 31 7 Total 491 40.3 51.9 ± 15.6 82 122 180 107 The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). subsequently used in the analyses. The characteristics of considered to be the most appropriate clothing style for the study participants are listed in Table 1. both male and female doctors, followed by scrubs and Figure 2 shows the influence of the six items evalu- smart casual clothing for men and scrubs alone for women. ated in the present study on patient confidence in Table 2 also lists mean scores for the each of the five doctors. Speech (mean [±SD] score 4.60 ± 0.68), reputa- clothing styles according to age group. Participants tion (4.06 ± 0.93) and attire (4.00 ± 0.94) were considered ranked the white coat style as the best for doctors of important by patients. Less crucial factors were doctors’ both genders. For some attire, the mean scores for the titles (3.04 ± 1.01), age (3.01 ± 1.04) and gender (2.73 ± 1.01). different clothing styles varied among the different age White coats were considered to be the most appropriate groups. Significant differences were found for the ranking style of clothing, following by scrubs, for both male and of scrubs (P < 0.01) and casual attire (P < 0.01) for male emale physicians. The other clothing styles (i.e. semi- doctors, and for scrubs for female doctors (P < 0.01). formal, smart casual and causal) were given lower scores. Elderly people considered scrubs less appropriate for Only 5.3% and 1.0% of participants thought that white both male and female doctors. Regardless of physician coats were inappropriate (score of 1 or 2) for male and gender, scrubs were rated significantly more highly by female doctors, respectively. A similar proportion of female participants, whereas male participants ranked participants thought scrubs were inappropriate for the smart casual style more highly for female doctors. male and female doctors (15.5% vs 15.1%, respectively). Significant differences according to age group, region However, a higher proportion of participants thought and gender were evident only for scrubs. A multivariate that semiformal, smart casual and casual dress was model was fitted to the factors, with Table 3 listing the inappropriate for both male (48.5%, 23.8% and 73.3%, OR for the inappropriateness of scrubs according to each respectively) and female (37.1%, 73.1% and 79.8%, respec- factor after adjustment for all others. The main finding tively) physicians. is a significant increase in the inappropriateness of There were significant differences only in mean scores scrubs according to participants aged 50–64 and >65 years for scrubs as a clothing style among the three regions compared with the younger group, with an adjusted OR (Table 2). In each of the three regions, white coats were of 4.30 (95% CI 1.24–14.90) and 12.7 (95% CI 3.64–44.8) for male doctors, respectively, and 3.66 (95% CI 1.22– 11.0) and 6.91 (95% CI 2.24–21.33) for female doctors, respectively. There was also a significant difference among regions in the appropriateness of scrubs, with a significant increase in appropriateness reported for female doctors in Region 2 compared with Region 1 (adjusted OR of 1.98; 95% CI 1.10–3.58). Discussion In terms of inspiring confidence and trust, participants rated a doctor’s speech, reputation and attire as quite important, but age, title and gender less so. However, each factor may make an important contribution to a Figure 2 Effects of six items on patient confidence in doctors. patient’s judgment of his/her doctor. Shah and Ogden Results show the mean scores on a five-point Likert scale for the reported that patients consider age and gender to be importance of speech, reputation, attire, age, title and gender on important because these factors relate to personal manners, patient confidence in doctors. as well as technical and explanatory skills [4]. In another Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 5 of 7 http://www.apfmj.com/content/13/1/2 Table 2 Evaluation of the appropriateness of different types of attire according to region in Japan and age group Region in Japan Age group (years) Region 1 Region 2 Region 3 P-value 20–34 35–49 50–64 65+ P-value Male physicians White coat 4.17 ± 0.94 4.10 ± 0.93 4.25 ± 0.89 0.38 4.32 ± 0.77 4.18 ± 0.86 4.04 ± 0.94 4.22 ± 1.06 0.12 Scrubs 3.66 ± 1.04 3.35 ± 1.10 3.58 ± 0.96 0.01 3.90 ± 0.86 3.75 ± 0.89 3.46 ± 1.04 3.08 ± 1.21 <0.01 Semiformal 2.58 ± 0.96 2.56 ± 1.05 2.66 ± 0.94 0.68 2.67 ± 0.90 2.57 ± 0.94 2.48 ± 0.96 2.74 ± 1.14 0.17 Smart casual 3.24 ± 1.12 3.22 ± 1.13 3.51 ± 1.01 0.07 3.35 ± 1.16 3.22 ± 1.01 3.18 ± 1.08 3.53 ± 1.18 0.50 Casual 1.96 ± 0.84 2.08 ± 1.00 1.89 ± 0.87 0.17 1.85 ± 0.79 1.87 ± 0.79 1.97 ± 0.92 2.28 ± 1.06 0.02 Female physicians White coat 4.38 ± 0.81 4.28 ± 0.78 4.32 ± 0.81 0.51 4.51 ± 0.65 4.30 ± 0.77 4.25 ± 0.80 4.35 ± 0.90 0.10 Scrubs 3.79 ± 1.04 3.35 ± 1.06 3.69 ± 0.99 <0.01 3.99 ± 0.84 3.87 ± 0.94 3.49 ± 1.05 3.16 ± 1.14 <0.01 Semiformal 2.89 ± 1.01 2.76 ± 1.01 2.94 ± 1.05 0.29 3.01 ± 0.95 2.80 ± 0.90 2.73 ± 1.01 2.98 ± 1.13 0.08 Smart casual 2.09 ± 0.92 2.02 ± 0.96 2.11 ± 0.92 0.68 2.15 ± 0.86 2.02 ± 0.87 1.98 ± 0.88 2.21 ± 1.12 0.19 Casual 1.93 ± 0.87 1.90 ± 0.93 1.82 ± 0.87 0.55 1.80 ± 0.79 1.86 ± 0.81 1.86 ± 0.84 2.06 ± 1.04 0.17 Data show the mean ± SD scores after participants had been asked to indicate the appropriateness of the attire shown in Figure 1 using a five-point Likert scale, ranging from 1 (absolutely disagree) to 5 (absolutely agree). The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). Analysis of variance (ANOVA) was used for univariate analysis. study, the tone of voice was significantly associated with to other factors. The importance of attire is not inferior, malpractice claim history [5], whereas Torres et al. found but actually rather high. that a physician’s reputation is positively associated Our finding that patients tend to prefer that doctors with patient trust and satisfaction [13]. Many studies wear white coats is similar to that reported by many have investigated factors affecting patient faith in doctors. other studies worldwide [1,6,7,15-19]. Despite differences However, few studies have been comparative. In the between countries, the white coat is a symbol of doctors, present study, we show the importance of attire in relation and it may create a sense of ease or confidence in patients. Table 3 Association between subject characteristics and the perceived “inappropriateness” of scrubs as clothing for male and female doctors Factor Male doctors Female doctors OR (95% CI) P-value OR (95% CI) P-value Gender Male 1.00 1.00 Female 0.77 (0.45–1.30) 0.33 0.67 (0.40–1.14) 0.14 Area in Japan Region 1 1.00 1.00 Region 2 1.78 (0.99–3.21) 0.05 1.98 (1.10–3.58) 0.02 Region 3 1.54 (0.69–3.41) 0.29 1.56 (0.70–3.47) 0.27 Age group (years) 20–34 1.00 1.00 35–49 2.11 (0.55–8.07) 0.28 1.38 (0.40–4.77) 0.61 50–64 4.30 (1.24–14.90) 0.02 3.66 (1.22–10.98) 0.02 65+ 12.77 (3.64–44.76) <0.01 6.91 (2.24–21.33) <0.01 The survey was conducted at five pharmacies in three regions in Japan, namely Ibaraki Prefecture (Region 1; two pharmacies), Niigata Prefecture (Region 2; two pharmacies) and Tokyo (Region 3; one pharmacy). In this analysis, scrub styles were divided into an “inappropriate” group (= 1) based on Likert scores of 1–2 and into an “appropriate” group (= 0) based on scores of 3–5, with these groups being defined as the dependent variables in binomial logistic regression analysis. The independent variables were gender, age group and region. The reference groups for the individual factors were male gender, age <35 years (younger group) and Region 1. OR odds ratio, CI confidence interval. Kurihara et al. Asia Pacific Family Medicine 2014, 13:2 Page 6 of 7 http://www.apfmj.com/content/13/1/2 In the present study, only 5% of participants regarded to them, with different colours perhaps eliciting different the white coat as inappropriate. Considering that physician reactions. So, using only one colour for the scrubs is also a attire is important to patients, white coats are an appropri- limitation of the study. Patients, especially elderly patients, ate clothing style for doctors. may have found it odd that doctors were not wearing In the present study, almost 40% of participants consi- white clothing, although scrub colours vary. Because dered a semiformal style, which is often seen in Japanese younger people have seen colourful scrubs in TV dramas, hospitals, as less appropriate. The preference for this such as “ER”, they may not find the red scrubs incongru- clothing style has varied among studies [1,6,14]. For ous. Thus, it may be necessary to clarify the relationship example, Lill et al. reported that the semiformal was between patient age and their preference for the colour of the favourite style in New Zealand [12], yet Yamada physicians’ attire. et al. found that patients do not like this style of clothing The present study has demonstrated the importance in Japan [1]. The findings of Yamada et al. were echoed of physician attire in patient perceptions. However, the in the present study in other regions in Japan. influence of a particular style of attire may last only a Patients tended to think that scrubs were almost as short time. Thus, it is necessary to clarify whether clothes appropriate as white coats, but the inappropriateness of can influence long-term patient–doctor relationships. scrubs differed according to age and regions. Elderly people regarded scrubs as less appropriate than did Conclusions younger people. The same finding has been reported in We have shown physicians attire after the speech and the UK [6]. Doctors could consider this when attending reputation is one of the most important factor inspiring elderly patients. With regard to the difference between physician confidence in their physicians. We have shown regions, this could reflect different levels of recognition the importance of physicians’ attire in patient perceptions. of scrubs, which are relatively new attire for doctors, Specifically, it is an important factor inspiring physician although identifying such reasons was beyond the scope confidence. White coats were seen as the most appropri- of the study design. ate style for doctors, regardless of gender, followed by In 2007, the British Department of Health published scrubs. However, older study participants perceived scrubs guidelines for good practice regarding uniforms and work as less appropriate attire than younger participants. wear [20]. Because cuffs become heavily contaminated Competing interests and are more likely to come into contact with patients, The authors declare that they have no competing interests. the guidelines recommend wearing short-sleeved shirts or blouses and to avoid wearing white coats when providing Authors’ contributions patient care [20]. Surgical scrubs are more hygienic HK participated in the proposal’s design, coordination, and data collection, carried out the study and drafted and completed the manuscript. Takami M and comfortable for doctors; thus, they may become participated in the proposal’s design, and coordination, and in drafting more common attire in the future. In this case, it may the manuscript. Tetsuhiro M participated in the proposal’s design, and be necessary to inform elderly patients of the medical coordination, and in drafting the manuscript. All authors read and approved the final manuscript. virtues of this type of clothing. Acknowledgement Limitations We would like to thank Mirai INC., Kraft INC. and AIN Pharmacies INC., which There are several limitations to the present study. First, gave us an opportunity for conducting this survey. And we also would like to thank all of the staff of the five pharmacies who supported us in this survey. the response rate was only 35% and so there may be a This work was supported by JSPS KAKENHI Grant Number 24590598. problem with internal validity. However, the results (i.e. white coats and scrubs are the preferred clothing style) are Received: 12 July 2013 Accepted: 6 January 2014 Published: 8 January 2014 similar to those reported in a previous study conducted in Japan [1]. Thus, we think the reliability of the study References is acceptable. 1. Yamada Y, Takahashi O, Ohde S, Deshpande GA, Fukui T: Patients’ Second, we are unsure whether the pharmacies chosen preferences for doctors’ attire in Japan. Intern Med 2010, 49:1521–1526. 2. Druss RG: The magic white coat. 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Turner RN, Leach J, Robinson D: First impressions in complementary practice: the importance of environment, dress and address to the therapeutic relationship. Complement Ther Clin Pract 2007, 13:102–109. 17. Rowland PA, Coe NP, Burchard KW, Pricolo VE: Factors affecting the professional image of physicians. Curr Surg 2005, 62:214–219. 18. Douse J, Derrett-Smith E, Dheda K, Dilworth JP: Should doctors wear white coats? Postgrad Med J 2004, 80:284–286. 19. Keenum AJ, Wallace LS, Stevens AR: Patients’ attitudes regarding physical characteristics of family practice physicians. South Med J 2003, 96:1190–1194. 20. Uniforms and workwear:an evidence base for developing local policy. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_078435.pdf. doi:10.1186/1447-056X-13-2 Cite this article as: Kurihara et al.: Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pacific Family Medicine 2014 13:2. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Jan 8, 2014

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