Insights November 2009

The Best-Dressed Doctors: No Ties, No Diamond Rings

Neil Seeman

Thanks to colleagues Erik Hellsten and Jerry Koh, I learned that the phrase, "how to tie a tie" is among the most popular search queries typed into Googleâ„¢. This does not surprise me, since tying an elegant knot is always a struggle, and appearance counts to many.
How important is appearance for healthcare providers? The results of a survey conducted this year in Britain showed that patients believed that doctors' dress was important, but they did not necessarily expect neckties and white coats. Surgical scrubs were considered acceptable forms of attire. The main issue for patients was distinguishing between a doctor and the myriad other hospital workers who swarmed around them whilst they were ill. They wanted to be able to identify who was who in a hospital and how junior or senior that person was.

The results of another study indicate that 85% of patients want doctors to wear name badges in a clearly visible place. Online chatter confirms as much; on social networks and blogs, patients and family members routinely express confusion about the role and identification of caregivers whom they encounter when in hospital. Many posts on the popular doctor rating site,, reflect this. One patient complaint about an obstetrician reads: "She came in the room without scrubs, a doctor coat, or even a name tag!! I am very disappointed with her and sadly with the … center because of it."

Neckties, however, don't help tell us who anyone is. They're just adornments, and noxious adornments at that. Times have changed since 1987 when 37% of patients believed male physicians should wear neckties. Little did that 37% know that doctors' ties are teeming with bacteria. A recent study compared bacterial counts from the ties and shirt pockets of 50 doctors. Bacterial counts were significantly higher from the ties (that were rarely, if ever, cleaned) than from the shirts that tended to be laundered at least every 2 days.

Formal appearance matters less (or should) than hygiene. It has been known for years that ties spread infection. A tie dangles in the air when the doctor bends over to examine a patient. It can brush past any number of germ-laden objects. Once bacteria accumulate on the surface of the tie, they are readily transmitted to the next patient, a form of doctor-borne infection. A study from the New York Hospital Medical Center of Queen's, N.Y. compared the ties of 40 doctors and medical students with those of 10 security guards.  About half the ties worn by medical personnel were found to be reservoirs for germs, compared with just one in 10 of the ties taken from security guards.

This year the British National Health Service imposed a 'bare below the elbows' rule. The rule bars doctors from wearing either ties or long sleeve shirts, both of which are known to be germ spreaders.

That's because neckties are not like hands that get dirty but get scrubbed many times a day. Dry cleaning shops report that it is very rare for customers to send ties for cleaning after just one wear. Most men will wear a tie at least twice before sending it for dry cleaning. Many will dry clean their tie only when it has a stain (I'm in this camp).  One might intuitively think that bow ties would solve the problem but one study examined differences between regular ties and bow ties with respect to contamination and found there was no difference to speak of. 

All healthcare providers, male and female, need to be tirelessly alert to spreading infection. Identity badges and lanyards worn by hospital staff are also contaminated with pathogenic bacteria. A low-cost solution might be for care providers to show their patients a current picture, title and other identifying information on their (well scrubbed) smart phone prior to every interaction.

Care providers have been asked to avoid wristwatches, bracelets and rings, and false finger nails. Nail polish is also a known source of infection. Studies have shown that despite infection control guidelines recommending that false fingernails, nail polish, stoned rings and wrist watches not be worn by clinical staff, a large proportion of doctors are disregarding the rules. But the best-dressed doctors leave their engagement rings and fancily-knotted ties at home. In times of flu, or at any time, hospital hygiene should supersede fashion.

About the Author(s)

Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.


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