At a recent medical staff meeting, my colleagues and I had a lively discussion about a new dress code adopted by the agency we work for. In an effort to foster the professional appearance of the employees, several changes to the dress code were announced. Among these was prohibition of jeans, T-shirts, flip-flops, revealing clothing, and the like. One of our colleagues voiced a concern that the new dress code policies went against the spirit of “stigma reduction” in the sense that to make ourselves more approachable to our patients, we should avoid the sort of dress that might make us appear somehow superior to them. Indeed, as part of orientation training at our hospital, we were told that patients felt most at ease with staff members who dressed in the same style as they did. This idea has been implemented so well at our hospital that it is often very difficult to tell staff members from patients, hospital badges on the former and parkinsonism in the latter being at times the only distinguishing characteristics.
That approachability has something to do with familiarity is obvious. Opposites may attract, but people tend to gravitate to those who resemble them most. There is no great leap of logic in assuming that someone dressed in jeans, flip-flops, and a T-shirt may feel more comfortable around those similarly dressed than around a person wearing pressed khakis, oxfords, and a button-down shirt. However, is our “dressing down” therapeutic for our patients? And, to what extent is our dress an accurate and honest reflection of our position?
In psychiatry circles, much has been said over the years about physicians’ paternalism and the stigmatization of mental illness and the mentally ill. From an insider’s point of view, it has been interesting to notice that many practitioners of a specialty that has struggled to be recognized as possessing legitimate medical expertise have also felt very uncomfortable with the authority implied by the possession of such expertise. Somehow there is a subtle reluctance to admit that, at least in the field of medicine, the doctor knows more than the patient and is the expert in the area in which the patient is having trouble. I have wondered whether this phenomenon is not more pronounced in psychiatry than in other medical fields, such as surgery, where the difference between the knife wielding doctor and the unconscious patient is rather harder to ignore. That there are doctors and there are patients implies that somewhere there is a line between health and illness. That those who are ill want to get rid of what is bothering them also implies that what ails them is not a desirable thing to have. Although it seems self-evident that people do not like to be ill, the notion that illness is not desirable and that some illnesses are less desirable than others has come to be known as stigma against those conditions. At the same time, there exists the notion that we ought to spare the feelings of those suffering from undesirable conditions. Since even in an effort at feeling-sparing no one could sensibly argue that such undesirable conditions are actually desirable, it has been argued instead that people with undesirable conditions are just like people without those conditions, or putting it only slightly differently, that the line dividing patients from doctors is illusory. Dressing down, it turns out, is one way of blurring the distinction between patients and those who treat them.
The relationship between the doctor and the patient is inherently unequal. Although in psychiatry this inequality is most pronounced in settings in which the patient undergoes involuntary treatment, it exists in the most voluntary of arrangements. After all, the doctor is assumed to possess some skill or expertise that the patient lacks and is in need of. The doctor is in need of getting paid, but outside private practice settings, the reimbursement comes from a source other than the patient and this reduces the doctor’s need for a particular patient. The patient’s needs, expectations, and hopes are directed toward the physician to a much greater extent and for reasons quite different from those running in the other direction. The relationship is unequal from the start and by its very nature. This fact can hardly be disputed, but there has been no shortage of attempts to minimize it or at least to pretend to do so. Before we deny or minimize the obvious, it would behoove us to ask whom this benefits and whether we can do so while maintaining integrity and honesty toward the very patients whom we are trying to help.
Dr Vatel is a Staff Psychiatrist at Evansville State Hospital and Lecturer in the department of psychology at the University of Evansville, in Evansville, Ind.