The white coat still “works” — but female doctors are often mistaken for non-doctors

An updated systematic review of how patients perceive doctors' clothing has been published in BMJ Open. The results are unsurprising and contain some unpleasant nuances: white coats are still associated with professionalism and trust, but female doctors in white coats are more often mistaken for nurses or assistants. The pandemic has shifted tastes in favor of scrub suits, especially in emergency and "risk" departments. And preferences also depend on the specialty and context - so a single "dress policy for all occasions" loses its meaning.

Background

• Why Doctors’ Clothing Isn’t a Small Thing. Appearance is the first signal in patient–doctor contact; it influences trust, perception of professionalism, and willingness to follow recommendations. An earlier systematic review showed a general trend: patients often prefer formal style and a white coat, although the context (country, department, patient age) significantly modifies tastes. An updated review in 2025 confirms: the coat remains a “symbol of competence,” but there are important caveats around it.
• Infection control versus “long sleeves”. In the UK, the bare below the elbows principle applies: short sleeves, no watches/jewelry; gowns are not recommended during care, as the cuffs are easily contaminated and come into contact with the patient. At the same time, there is little direct evidence that gowns increase the frequency of HAI; but studies consistently find contamination of white gowns (including MRSA) and less frequent washing compared to scrubs. Hence the cautious regulations and local dress codes.
• The COVID era has shifted the pendulum towards scrubs. Studies from 2020 to 2023 recorded an increase in the preference for scrubs and greater “acceptability” of masks in outpatient practice — patients began to value the hygiene and practicality of clothing more highly. This shift is especially noticeable in emergency care and “risk” departments.
• Gender bias and “misidentification.” A number of studies have shown a persistent phenomenon: female doctors are more often mistaken for nurses or assistants even when dressed the same, and their appearance is assessed more harshly. An updated review in 2025 notes the same problem and calls for obvious role markings (DOCTOR badges, etc.).
• The specialty and place of the appointment decide a lot. In outpatient clinics and elective departments, patients often prefer a formal style + a gown; in emergency and surgery (especially post-COVID) - scrubs. In palliative care, the type of clothing has less of an impact. That is, a “uniform” dress code for all occasions gives way to flexible rules by zone.
• There is a clothing effect, but it is not uniform and not always “strong”. Several reviews highlight that preference for white coats and formal attire does not always translate into a measurable difference in treatment satisfaction; the strength of the effect depends on culture and clinical context; and many studies are surveys/vignettes rather than real behaviour.
• Historical and symbolic layer. The white coat is part of professional identity (White Coat ceremonies, etc.), a symbol of purity and science; but in the 2000s–2010s, a “re-evaluation” began due to infection control. Modern recommendations try to balance symbolism and safety: short sleeves, frequent washing, clear role markings.
• Why the 2025 update was needed. In the wake of the pandemic and amid discussions about equity in medicine (including gender hierarchies), it was necessary to reconcile disparate data: what patients think now, where the gown helps communication and where it hinders, and what measures reduce bias (badges, standardized signatures, staff training). The new review answers precisely these questions and offers context-sensitive solutions.

What exactly did they do?

The authors reviewed the literature from 2015 to August 2024 and included 32 studies from 13 countries (mostly from the United States) in their analysis. They looked at how patients see a “professional,” who they trust more, and how this changes from department to department. This is an update to previous reviews, taking into account that hygiene standards and patient expectations have changed significantly since COVID-19.

Key findings

• A white coat is a sign of professionalism and cleanliness. In most contexts, patients rate trust and competence higher if the doctor is wearing a coat (often over formal attire or scrubs). This is true for both men and women.
• The gender bias is persistent. Even with the same attire, female doctors are more often not recognized as doctors (they are listed as nurses/assistants). The authors emphasize that these are not isolated cases, but a repeating pattern across cultures.
• Context matters.
  • In emergency and high-risk departments, patients are more willing to accept scrubs (with an emphasis on hygiene).
  • In a number of surgical and procedural specialties (orthopedics, surgery, dermatology, ophthalmology, OG&R), gowns and formal suits are still “in favor.”
  • In palliative care, the type of clothing often does not influence trust and assessment of competence.
• The pandemic has affected tastes. Research conducted during the COVID era and beyond has recorded an increase in loyalty to scrubs and masks — patients have come to value practicality and cleanliness more.
• Regional policies play a role. For example, the UK has a “nothing below the elbow” rule (no gowns/long sleeves/ties/watches) in the name of infection control – and this conflicts with the normal expectations of some patients.

Why is this important?

Appearance is the first signal in the patient-doctor meeting. It affects trust, a sense of respect, and willingness to follow recommendations. If clothing works “for” the doctor, it is a plus for communication. If clothing works against female doctors, it is a question of fairness and quality of care. The authors directly recommend that institutions take into account gender and contextual effects in clothing regulations and reduce bias among patients and staff.

What clinics should do (and it’s real)

• Flexible dress codes "by zones". Some requirements for the reception/intensive care unit (scrubs, clear role markings), others - for outpatient clinics and elective departments (formal clothes + gown). Identical badges with a large "DOCTOR" help "re-sew" incorrect expectations.
• Anti-bias practices. Train staff and inform patients: who is in front of them and why this type of clothing was chosen (hygiene, safety). This reduces the “noise” around appearance and builds trust.
• Test local preferences. Tastes vary by department and region; short patient surveys and A/B pilots with different dress codes are a quick way to tailor rules to your audience.

Viewing Limitations

Most of the included studies are from the USA; there is little data from South America and some countries in Europe/Asia/Africa. Most often, surveys and photographs/vignettes were used rather than an actual visit; there were no children or psychiatric patients. Therefore, the conclusions are general guidelines, and not "once and for all countries".

Source: Patient perception of physician attire: a systematic review update, BMJ Open, published 12 August 2025; DOI: 10.1136/bmjopen-2025-100824.