AMA Journal of Ethics^®

Your brand-new family doctor walks into the waiting room, spots you, and hurries over to introduce himself. He slaps you cheerfully on the shoulder and then booms: "Hiya, Bob! I'm Dr. Hotchkiss! What's up?"

Which of the following responses (A,B,C,D) shows the best understanding of medical etiquette, as you begin the important task of building a good "doctor-patient relationship"?

A. Hoping to win your new physician's approval, you nod politely, shake the hand of this impressive authority figure . . . and then murmur respectfully: "It's a privilege to meet you, sir."

B. Doing your best to prove that you can be just as chummy and informal as the doctor, you slap his shoulder, while barking enthusiastically: "Great to meet ya, Doc! When are you free for a round of golf?"

C. Enraged by the doctor's breezy, patronizing use of your first name—while he insists on referring to himself as "Dr. Hotchkiss"—you snap furiously: "Stop calling me Bob! And if you touch my shoulder again, I'll have you arrested for battery!"

D. Speaking politely but firmly, you tell the doctor: "Before we start talking about medical issues, we need to discuss our relationship . . . including the way that we're going to address each other. I need to feel that there's trust and respect on both sides"¹.

The "dotcom" revolution of the 1990s brought with it many changes. One of the more enduring is the movement toward casual dress in the workplace. Suits and ties are out. Polo shirts and khakis are in. Ninety percent of US companies allow some form of casual dress, up from 62 percent in 1992². Traditionally staid employers such as law firms and banks are enthusiastically jumping on the casual bandwagon, though some still require formal attire for interactions with clients. Employers argue that it is a perk that improves worker morale, yet costs nothing.

This "casualization" in the workforce is but one component in a larger cultural trend in which social relations and forms of address are less formal than they were a couple of generations ago. Adult peers typically dispense with formal titles of address (Mr. or Ms.) and usually move directly to a more familiar first-name basis. This may reflect a certain democratization. It also may reflect the influence of youth culture, where informality and spontaneity are greatly prized. Is society better off with more formal or informal styles of dress and address? Is this an ethical issue or one of mere etiquette? Does what we think of as "mere etiquette" have some ethical significance? Going back to the opening scenario, does physician etiquette affect the therapeutic relationship?

Casualization has indeed influenced dress and behavior within the health care arena. Nurses long ago shed the white uniform and cap for more practical and comfortable garb. Certain television shows, such as ER, have helped popularize the surgical scrub as the uniform de rigueur in medicine. Some places, however, attempt to draw the line in casualization. Take, for example, the following admonition against the ubiquitous scrub in an orientation guide of new residents at an academic medical center:

"The . . . clinics operate in a casual atmosphere that seems to make the patients feel more comfortable and responsive. Many of the employees, nursing personnel and physicians dress in a casual manner. Although a tie for men and similar level of formality for women is preferred, more casual clothing is acceptable so long as it is clean and in good repair. Scrub suits are not acceptable."

Another academic medical center reinforces the notion that casual dress may not be in the best interest of the patient-physician relationship:

"A physician's appearance serves as a powerful, nonverbal symbol that affects communication between doctor and patient. Patients react negatively to jeans, athletic shoes and socks, scrub suits, clogs, prominent ruffles, dangling earrings, and excessive aftershave lotion or perfume. Patients express preference for well-trimmed hairstyles"³.

Physicians have mixed responses to these matters, as exemplified in an exchange of letters in the Newsletter for the American Society of Anesthesiologists⁴. One physician claimed that "[y]ou have to 'talk the talk', 'walk the walk' and 'dress the dress' if you want to be recognized as a physician." Another stated that "[w]hen it comes to our attire, anesthesiologists need to stop being so egocentric: we dress for our patients and for the professionals with whom we work, not for ourselves." And a third added "[h]ow many times has the perception that we are slobs affected interactions with the public, other physicians, hospital administrators and health care organizations?" But a dissenting voice felt that "[n]o amount of gaudy, expensive dress will ever make some anesthesiologists professional . . . a physician can act professionally regardless of what he or she is wearing."

The range of perspectives represented in these comments points to the larger question: Does casualization compromise the therapeutic relationship? There are those who argue that physicians' professional wear and behavior play an instrumental role in their communication with patients, inspiring confidence and credulity and indicating respect and a desire to please. If this is indeed the case, casualization may indicate a significant change in how physicians choose to relate to their patients—one that could have consequences for patient care and deserves to be looked into further. On the other side of the debate are individuals who claim appearance and attitude are mere matters of social etiquette. A physician's medical abilities are what really matters; questions of dress and address are frivolous criteria by which to judge a professional responsible for promoting medical well-being.

Whether casualization in the doctor-patient interaction is one-sided or reciprocal may color general reactions to the trend. If the relaxing of social etiquette norms is exercised only by physicians, it could reinforce the power differential that already exists between patient and physician, rather than foster a more comfortable environment for all. The white coat worn by physicians has long been criticized as a symbol of power that skews the medical encounter. Now its shedding seems like it could engender the same types of complaint, if it isn't accompanied by a corresponding trend toward patient's leaving formality behind. If patients continue to dress up and use titles and last names when they address medical personnel, while physicians dress down and adopt first name designation, casualization could steer us in a direction we have tried to avoid—toward an almost patronizing system where one party is paid more respect.

So Dr. Hotchkiss (no matter what you're wearing), before you slap Bob on his back, give some thought to whether you want him to call you "Joe."