A few years ago, I was looking for a new primary-care doctor. I was hoping for someone who was kind, smart, and caring, someone who’d listen with full attention. I didn’t care what the doctor looked like—or so I thought, until a woman clicked into the room in stilettos and a tailored expensive-looking suit. This wasn’t a case of a low-cut blouse or a thigh-revealing skirt. And yet I felt put off. I felt like a slob. The doctor was nice enough, perhaps a little brusque, or maybe her clothes were brusque, and I didn’t end up sticking with her. What I remember most was the feeling that she had somewhere more important to be, like a board meeting, where the discussion would involve the business of medicine rather than the art of it.

Maybe it wouldn’t have bothered me if I were meeting her at the Mayo clinic, where all doctors wear business suits—a uniform, really—where I would have expected it. Or if she were a cosmetic surgeon, a field where it behooves a doctor to look chic and well-coiffed, with skin as silken-smooth as the ubiquitous subway skin doctor Jonathan Zizmor. But primary-care medicine is a different beast, where it’s less about a couple of visits for Botox and more about the relationship between doctor and patient, which ideally will last for years and years.  And what the doctor wears—part of the patient’s first impression—can have an effect.

In medical school, students learn to note a patient’s appearance and clothing (words like “disheveled” or “well-groomed” seem to pop up a lot in the medical record).  They’re taught to interpret the patient’s gestures and eye contact, or lack of it, and to think about their own body language.  And yet, somehow, the topic of doctors’ own clothing rarely comes up, save for the most flagrant lapses (plunging necklines, jeans, T-shirts) or the simple and vague admonition to appear “professional.”

“Professional” is a tricky word in a clothing context. It’s possible, of course, that other patients found the stiletto doctor’s business attire entirely appropriate, a reassuring hat-tip to the doctor’s traditional stature. In days of yore, the doctor was clearly identifiable by the white lab coat over shirt and tie, his agreeable nurse counterpart unmistakable in white dress and cap (which, depending on one’s school, might be shaped like a coffee filter, sailor’s cap, or a hamantaschen).  But in the 21st century, especially in primary-care medicine, much has changed; with more categories of clinicians (nurse practitioners, physician assistants) in every sphere of medicine, the traditional clinical clothing boundaries have blurred.

The definition of what counts as professional clothing is also in flux, thanks to increasing knowledge of infectious risks. Earlier this year, the Society for Healthcare Epidemiology Association (SHEA) published new guidelines for healthcare-personnel attire in hospital settings. Their goal was to balance the need for professional appearance with the obligation to minimize potential germ transmission via clothing and other doodads like ID badges and jewelry and neckties that might touch body parts or bodily fluids. The SHEA investigators' take-home points regarding infection: White coats should be washed weekly, at the minimum; neckties should be clipped in place (70 percent of doctors in two studies admitted to having never had a tie cleaned); and institutions should strongly consider a “bare below the elbow” (BBE) policy, meaning short sleeves and no wristwatches or jewelry. Although the impact on reducing the risk of infections remains to be determined, it’s considered potentially significant enough that a number of countries have adopted BBE requirements for all clinicians. (And it leaves me wondering: When will the Mayo clinic update its dress code to short-sleeved business suits?)

The report also addressed the question of what patients want their doctors to wear. The short answer from the SHEA investigators, who reviewed 26 studies of patient perceptions of doctors’ clothing, was that patients prefer that doctors appear “formal” rather than “casual.”  But forcing all clothing-description categories into one or the other of those two somewhat vague terms is misleading. Here’s why: In those studies (including one that was satire and shouldn’t have been included), there were abundant ways of describing clothing with so many different scales and definitions of formal versus casual it would make your head spin. Consider a few of the many systems for categorizing outfits: A man’s shirt and tie was “formal” in one study, “semiformal” in another, and elsewhere “business” and “professional informal.” A woman’s dress or skirt was “formal” in one, “business” in another. Slacks and a pullover shirt or blouse: “casual” in one, “smart casual” in another.               

Perhaps the proper conclusion is that there is no one “right” way for doctors to dress. While every patient wants their doctor to look decent, there’s a range of what’s acceptable, and context matters. Facial expressions and body language communicate as much as words; clothing, similarly, should blend seamlessly with a doctor’s ability to emanate trustworthiness, competence, and caring. During a visit to a patient at a local hospice, I was struck by one of the doctor’s outfits: He dressed simply but neatly, in brown corduroy pants and a sweater vest, his sleeves rolled to the elbow. His clothes gave one the sense that he had all the time in the world to schmooze with his patients and their families.

I suspect that he chose those clothes because they made him feel that way, too, like he could kick back, put his feet up on the windowsill, and just be there, for as long as it took. There’s a term for the way that clothing and physical sensations trigger abstract concepts: embodied cognition. A few Halloweens ago, when I dressed as Sarah Palin in a close-fitting suit, lots of red lipstick, my hair piled in an aggressive teased bun, I felt brash and bumptious. Perhaps the stiletto-wearing doctor felt similarly bolstered by her designer duds; perhaps it was her way of surviving in a world that gives more power to her male colleagues. But we doctors present different sides of ourselves to colleagues and patients, and more down-to-earth clothes can diminish the power differential between provider and patient and make the process of connection easier.

Last week, two days in a row, I ran into a colleague who’s a pediatrician. The first day, she wore a beige pantsuit (I’d label it formal, or business) and looked fairly corporate. I wondered to myself if she realized that her clothes were sending a message to her patients, a message that indicated that her medical practice was a business and that she wielded the power. The next day, she wore a loose-fitting knee-length navy dress (professional informal, perhaps, or smart casual). I asked her if she had seen patients the first day. She had not; it was a day of meetings, and when I told her I was writing about doctors’ clothing, she laughed. “When you’re seeing patients,” she said, “you have to look like you’re not afraid to get dirty.”               

Would the stiletto-wearing doctor squat down to examine a sore on a wheelchair-bound patient’s foot, or roll up her linen sleeves in preparation for a Pap smear? I suppose she would. But I’d rather see someone whose clothes didn’t leave me wondering. Give me a warm-hearted doctor with an open, interested expression, and I might not even notice what she’s wearing.