Recently, because of some injuries and need to purge a few items of clothing from my usual code of adornment, I was tieless and shoeless (sneakers instead) for several weeks. No decorum faux pas here, as my generation of practitioners seem to have adapted to this style of dress, say, on holidays or weekends—right or wrong.
However, never on Monday to Friday will this fly, as the “shoe and tie” thing is still the norm during regular business hours. Or is it?
I was liberated for this interval of time, felt freer to practice, and move about the cabin as they say. No motivated reasoning here, but I always felt that “looking elegant or meticulous” on the wards was counterproductive and the ER docs have it right. Comfort is king and debatable as the merits might be, collared long sleeve shirts, jackets, ties, etc., always appeared out of place. Their vector potential for microbe transmission was also always suspect in my book. At least more so than scrubs or other hospital specific apparel.
I am not a fashion zealot at work, and like life, I suppose it is always formulaic: khaki’s, comfortable shoes, solid or striped oxford, and a tie with a little bit of life. In conversations with other XY encoded docs, despite the occasional fashion template in the crowd, this is a common phenomenon: there are work clothes…and everything else.
I am not the only one on this, trust me—my own personal field research is valid. There are the ‘A’ list ties, and the ‘B’ list ties, and never the twain shall meet. Once a tie on the A-list (weddings, Bar Mitzvah’s, fine dining) is banished because of stains, rotational demands, etc., there is no turning back. It goes to the AAA leagues and does not return. Think I am kidding:
Yes, that is my closet. On the left are the work ties, and on the right are the chosen ones. The latter, well, they will not make appearances on the telemetry ward any time soon.
Same for pants:
Upper is work, lower for living. End of story.
Here is the thing though. I do like nice clothes and can toss an ensemble or two together in a pinch–seriously. I was heartened at last year’s resident graduation ceremony, having busted out the Brooks Brothers suit, European wing tips, imported silk pocket square (I could go on :-)), and hearing from many trainees, “geez Dr. Flansbaum, you clean up awful nice!” It made me feel darn good.
However, there are more factuals from my closet: cashmere sweaters. Check. Seersucker suit. Check. Suede and velvet sport coat. Check. Cuff links and tailored shirts. Check. Heck, I even like wearing pink.
A solid list with lots of nice items, but here is the thing. First, I never have the opportunity to wear them, and second, there is no way, no matter how first-class I wish to appear, would I don them in the hospital.
Joking aside, I do feel decorum is important, and additionally, now that patient satisfaction (? and impressions) are national priorities, our appearances have consequences.
I read with interest the sporadic studies on physician dress and patient reaction, as well as the infection producing potential of ties and long sleeve shirts, here, here, here, here, and here. Hospitalist confusion lingers amidst a bevy of issues: patient first impressions, the conservative legacy of formal dress codes of a bygone era, comfort, infection control, and ultimately, societal opinions of appropriateness.
As hospital-based practioners, we are witnessing and shaping a new normal. Absent hard data, opinions are just that, opinions. However, patients accept, and probably welcome ED personnel in their “trauma” garb. It is a confidence thing, and television shows like ER assisted.
As full time ward attendees, given exposure to bodily fluids and then some, are our work demands any different? Does the data apply to us as well, or only to physicians in their examination room down the street? Do effects on day one (“who is the doctor in the ripped scrubs”) linger, when on day two (“geez, that doc is so sweet…and he called my physician brother in Duluth like I asked him”), the patient has a different perspective as they see your genuine aims unfold?
I do not know the answers.
What I do know is the hospital is singular as a practice node, as is the nature of what we do (along with intensivists and ER docs). Not to overlay casual over appropriate, but I am rethinking what is “normal” on the wards and what is best for doctor satisfaction (important), patient impressions (more important), and infection control (most important). I want to emphasize, I am not referencing open toe sandals, belly shirts, or branded tee shirts. No way! Professional, antiseptic, neutral appearing clothing that is comfortable and agreeable is my sole objective.
I have military tucked my tie for years (my trademark), as a misbehaved tie while leaning over a patient’s bedside leads to mischief.
My sleeves—always roll them up.
My lab coat is hanging untouched on the back of my office door. Why expose patients to a stain vector daily unless you intend to clean it come quitting time qd.
Perhaps AHRQ (or a designer house) has a grant for this burning issue. Seriously, this is a bona fide query. What should a hospitalist wear when plying their craft? Is this more in versus outpatient medicine variance, or much ado about nothing? I am curious to hear from others, and Giorgio Armani can pipe in if he chooses.
UPDATE: This from the latest JHM. Of interest, and directly applicable to above. But as investigators point out, generalizability limited; MRSA examined only, outcomes not measured, and hand washing, environmental variations between wards, etc., not explored. One piece in a bigger puzzle and more data needed to clarify approach.
UPDATE #2: NYS Law advances bill.
On some miscellaneous issues:
- This is the most compelling piece I have read on medical rationing in some time. Read closely, as the subtext whispers a persuasive case for IPAB.
- This month, I have two fine interns, and our discussions have taken us to places I never imagined—thus, their “fineness.” Most recently, we veered into the meaning of patient compliance versus adherence, and patient-driven care. As a result, I reread Don Berwick’s seminal essay, Confessions of an Extremist, and we are discussing it next week. It has taken on a different meaning on the relook (I have not picked it up in two years). Whether I have evolved, the medical system has advanced, or it is something in the water, I cannot say, but I am more open to some of its revolutionary message (you will see, his positions are a major departure from current practice). If you have never read it, despite his tenuous position at CMS, bookmark it. It will get your attention.
- Again, fellow blogger Rachel Lovins making news. Check it out; her case is front and center in this week’s New York Times. Nice job!!
Finally, enjoy the lovely weather. It has been a long winter, and the flowers and greenery are looking just fine this time of year. Daylight savings dont hurt either!
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.