What do Australian junior doctors think of white coats?

Objective  To determine the attitudes of Australian junior doctors towards white coats. Methods  We carried out a multicentred mail survey in 13 Australian teaching hospitals. A total of 337 junior medical officers (JMOs) completed an eight‐item questionnaire. The survey sought to establish JMOs' views and preferences regarding the wearing of white coats and the reasons behind them. Results Very few Australian JMOs wear white coats. Many reasons for not wearing white coats were given, the most common being 'No one else wears a white coat' (70%). A total of 60% of JMOs are against wearing white coats; 24% are indifferent on the issue and only 16% expressed a general preference for white coats. Junior medical officers who did prefer white coats indicated reasons of convenience for carrying items, identification and/or professionalism, and hygiene and/or cleanliness. Conclusions White coats have largely disappeared from Australian teaching hospitals and the majority of junior doctors in Australia oppose the wearing of white coats.

Keywords: Australia; chi square test; clothing/*psychology; hospitals, teaching; questionnaires; sex factors; attitude of health personnel

White coats seem to have virtually disappeared from Australian teaching hospitals in recent years. This circumstance has prompted patient surveys and considerable discussion.[[1]] Australian surveys generally reveal that patients have more positive than negative attitudes towards white coats. Many patients, however, are indifferent on the issue and do not necessarily maintain the medical profession's preoccupation with white coats – probably placing more emphasis on general standards of dress and other professional attributes.

Whilst the white coat also seems to have become an endangered species in some British hospitals,[6] a divergent trend has emerged in the USA over the past decade. So‐called white coat ceremonies are now practised in the majority of US medical schools.[7] Although the ultimate goal of these ceremonies is to reinforce high professional and humanistic qualities,[8] they also emphasise the simpler sartorial and practical roles of white coats. Indeed, white coats are worn by almost all junior doctors ('house staff') in US hospitals.

Any hospital considering the reintroduction of white coats would very likely have medical students and junior doctors foremost in mind. Surveys of attitudes to white coats have ignored the junior members of hospital medical staff. We therefore conducted a survey of Australian junior doctors' attitudes to white coats.

This survey questionnaire was part of an overall national survey regarding junior medical officers' (JMOs) preferred sources of clinical information on the wards.

The survey was conducted in November 2001. A November survey gave us the opportunity to capture JMOs after they had had sufficient time during the year to make up their own minds about white coats. It was also a time of year of relatively neutral ambient temperatures throughout Australia.

Medical administrators in 13 selected teaching hospitals around Australia were individually contacted by telephone and mail prior to commencement of the survey. Packages of questionnaires including our eight‐item survey material were then sent to all medical administrators. They were asked to send or hand a copy of the questionnaire to each of their hospital's allocated JMOs. Each questionnaire included a prepaid reply envelope to be returned to the Postgraduate Medical Council of New South Wales. Junior medical officers were not individually identifiable by their returned questionnaires.

A JMO was defined as a doctor in either their first (intern) or second (resident medical officer: RMO1) year of postgraduate training, or an overseas‐trained doctor (OTD) undertaking a supervised year of training prior to obtaining full registration. All participants were asked to state their age, gender, primary hospital for 2001, whether or not they were in the habit of wearing a white coat on the wards at the time of the survey, and whether or not JMOs in their hospitals generally wore white coats on the wards. Three key questions then sought JMOs' views and preferences regarding white coats and the reasons behind them (Figs. 1–3).

Graph: 1 JMOs' reasons for not normally wearing a white coat. Responses to the question: Which of the following responses best expresses your reason for not normally wearing a white coat on the wards (you may circle more than one response).

Graph: 2 JMOs' views on white coats. Responses to the question: Which response below best expresses your view on white coats (circle one only).

Graph: 3 Reasons for preferring to wear a white coat (JMOs indicating items marked * in Figure 2). Responses to the question: Given that you would generally prefer to wear a white coat, which of the following responses best expresses your reason for this preference (you may circle more than one response).

One of the questionnaire items asked: 'Which response below best expresses your view on white coats?' Respondents who answered (A) 'I don't think resident doctors should wear white coats at all,' or (B) 'I would rather not wear a white coat but wouldn't mind if some other JMOs decided to wear them,' were categorised as being against white coats. Respondents who answered (C) 'I don't have a strong opinion but would be happy to wear a white coat if it's required,' were considered indifferent. Respondents who answered (D) 'I would prefer to wear a white coat but only if most of the other JMOs do the same,' (E) 'I would prefer to wear a white coat and don't really care what other JMOs do,' or (F) 'I think all JMOs should wear white coats,' were considered proponents of white coats.

Comparisons of views on white coats between genders and between positions (interns versus RMO1s versus OTDs) were calculated using the chi‐square test. The independent t‐test was used to compare the mean ages of those for and against white coats.

A total of 337 JMOs returned completed questionnaires. Respondents included 179 interns (53·1%), 122 RMO1s (36·2%) and 36 OTDs (10·7%). The sample included 178 men (52·8%) with average age of 27·2 years (range 23–51 years) and 159 women (47·2%) with an average age of 27·5 years (range 23–50 years).

Only one JMO in all 13 teaching hospitals normally wore a white coat on the wards. Over 98% of JMOs reported that none of their JMO peers wore white coats on the wards.

Of the eight offered reasons on the questionnaire, an average of 2·5 reasons were circled per JMO (Fig. 1). A clear majority (70%) of JMOs felt the fact that 'no one else wears a white coat' was significant reason not to do so themselves. Other common reasons included white coats making the wearer feel too hot (44%), looking too formal (31%), and being cumbersome to wear (30%). A significant minority of JMOs was concerned about the chore of cleaning coats and a belief that white coats are actually unhygienic in a hospital setting.

In all, 60% of JMOs were against wearing a white coat (Fig. 2). A total of 24% of JMOs were indifferent on the issue and only 16% expressed a general preference for white coats. Over half the JMOs in favour of white coats would only wear a coat if other JMOs did the same.

Women were more in favour of white coats than men (21% versus 13%; P = 0·048; χ2 = 3·91). Overseas‐trained doctors were significantly more in favour of white coats than interns or RMO1s (42% versus 14% and 13%, respectively; P < 0·001; χ2 = 18·3). Junior medical officers in favour of white coats were significantly older than those against (29·3 versus 26·9 years; P = 0·03); however, there was no difference in age profiles once OTDs were excluded from the analysis.

The 56 JMOs who indicated a preference for white coats expressed a broad range of reasons for their views (Fig. 3). The vast majority saw a white coat as a convenient way of carrying useful items. Over half indicated reasons of identification and/or professionalism and over half gave reasons of hygiene and/or cleanliness.

There are several important findings from this study. Firstly, our results strongly support contemporary observations that white coats have all but disappeared from Australian teaching hospitals. Although our survey involved only a sample of Australian teaching hospitals, we are not aware of any other hospital where white coats are still worn by JMOs. There are a few hospitals where medical students are still expected to wear coats.

Secondly, a clear majority of junior doctors in Australia are against wearing white coats. It is worth noting, however, that any hospital interested in reintroducing white coats may find that a substantial proportion of JMOs might actually be willing to comply. Although only 16% of JMOs were clearly in favour of white coats, a further 24% were prepared to wear white coats if required. Moreover, 65% of JMOs who were against wearing white coats indicated that one of the reasons they did not wear white coats was simply because no‐one else did. We believe our results truly reflect the views of junior doctors. It is possible that the prevailing absence of white coats at the time of the survey may have lead to response bias; however, we believe that the potential for such bias was minimised by offering JMOs a range of response options.

Thirdly, any hospital that does consider reintroduction of white coats would need to provide a free and reliable linen service that allows white coats to be changed weekly.

We believe this is the first study to examine Australian junior doctors' views on white coats. Our results affirm many of the established arguments both for and against wearing white coats.[[9]] Overall, we have identified a considerable degree of aversion to white coats amongst Australian junior doctors. However, given that partiality towards white coats still exists among a substantial proportion of patients and a significant minority of JMOs – and presumably a large number of older doctors – it is likely that the debate about white coats in Australian hospitals will continue for some years. Whether or not we will witness attempts to reintroduce white coats in the near future remains to be seen.

Both authors contributed to the design and implementation of the study, data analysis, and preparation of the manuscript.

We are grateful to the medical administrators of the following hospitals for distributing questionnaires to their JMOs: New South Wales – John Hunter Hospital, Royal Prince Alfred Hospital, Tamworth Base Hospital, Westmead Hospital; ACT – Canberra Hospital; South Australia – Flinders Medical Centre; Western Australia – Fremantle Hospital, Royal Perth Hospital; Queensland – Mater Misericordiae Hospital, Royal Brisbane Hospital; Tasmania – Royal Hobart Hospital; Victoria – Alfred Hospital, St Vincent's Hospital.

No conflict of interest exists.

This study was supported by a National Projects grant from the Medical Training Review Panel, Commonwealth Department of Health and Aged Care.

Very few Australian junior doctors wear white coats.

The majority of Australian junior doctors are generally against wearing white coats.

Junior doctors' negative attitudes to white coats are influenced by peer group practices, as well as concerns about formality and comfort.

A significant minority of junior doctors would wear white coats if required.

Any hospital considering reintroduction of white coats must take into account the attitudes of junior doctors.

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