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Want to look "professional" in healthcare? Wear a white coat, and over office-type clothing, not scrubs. Especially if you're a woman.

On the other hand, if you're a surgeon, scrubs under the white coat actually add to your perceived professionalism. And nobody should wear fleece vests or softshell jackets (even when embroidered with names and institutional logos) if they want patients to think they know what they're doing.

These are some of the highlights, if we can call them that, of a in JAMA Network Open. About 500 laypeople were asked to rate professionalism and guess the job classes of male and female models in different types of clothing often worn by healthcare workers.

The authors, led by Helen Xun, MD, of Johns Hopkins University in Baltimore, were quick to argue that the findings suggest that the industry has work to do in overcoming biases based on gender and clothing choices.

Probably the least surprising finding in the study was that women were significantly less likely than men to be taken as physicians, no matter what they were wearing. Women also drew lower "professionalism" ratings than men when they wore white coats over business wear or were clad in scrubs -- but curiously, not when the attire was scrubs underneath other garments.

That, however, wasn't the researchers' main interest. They conceived the study primarily to examine the growing trend favoring more casual clothing for healthcare workers, including vests and jackets worn either over scrubs or office attire.

A wealth of previous research had looked at patient perceptions of traditional white coats and scrubs, Xun and colleagues noted. But questions and concerns have arisen around the white coat particularly, as an agent for potentially transmitting pathogens and also because it can get in the way of certain medical functions.

In addition, the researchers pointed out that the white coat carries a subtle connotation of superiority in the healthcare hierarchy, and with recent emphasis on teamwork in healthcare, "the white coat has appeared to some as an antiquated relic."

Consequently, the group wrote, "practitioners may wear the casual attire as a more modern alternative in place of the white coat owing to comfort, ease of transition to and from work, and/or practical reasons such as warmth or weatherproof function."

For the study, Xun and colleagues recruited and surveyed adults through Amazon's Mechanical Turks service. Participants' mean age was about 36 and around 76% were white, with an even split between men and women. Some 20% were healthcare workers themselves (about the same as in the general population), and 60% had at least one hospital stay in their past.

Participants were shown photos of models wearing various combinations of white coats, scrubs, and softshell jackets and pullovers, some with office wear underneath and some with scrubs. In one series, participants were told that the models represented family physicians, dermatologists, or surgeons, and were asked to rate each according to their perceived experience in healthcare and overall professionalism. Another phase asked participants to guess whether the model was a physician, surgeon, nurse, physician assistant, or medical technician.

White coats were the clear winner for the family physician and dermatologist, whereas scrubs either on top or underneath drew higher ratings for surgeons. Overall, the white coat over business dress came in with a mean experience rating of about 5, versus 3 for all other attire combinations (P<0.05); scores were similar for ratings of professionalism.

Xun and colleagues were struck by one particular finding: "the tendency of respondents to rate a model wearing either a gray fleece jacket or a black softshell jacket as less experienced and less professional compared with a model wearing a white coat." The researchers hypothesized that, because such casual wear is a relatively recent phenomenon, participants may not have seen it often in real-life healthcare, and thus wouldn't connect it to "valued physician characteristics."

The group also observed that replacing white coats with casual attire, to the extent that it's driven by concerns about cleanliness, could be a mistake, since there's no obvious reason to assume that fleece vests or jackets would be any less vulnerable to contamination. Xun and colleagues acknowledged that providers must take patients' perceptions, whether rational or not, into account as they seek to build rapport.

That does not mean that the white coat must remain supreme, though.

"[T]he introduction of new physician attire presents a disruptive opportunity to address persistent gender biases in medicine," the researchers wrote. "With exposure and education, public perception of physicians can be broadened to reflect increasing diversity as the new status quo. This includes clear identification of professional roles during introductions, immediate correction of role misidentifications, and increased visibility (such as more diverse representation at all levels of training; spotlight features; representation on boards, as speakers, and in leadership positions; and presence on social media)."

Moreover, they added, it's imperative that this effort be undertaken by all healthcare professionals, not just those (such as women) who suffer from biases in the workplace.

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