Dr. Joel's Response to UCSD's Dress and Appearance Policy

Yes...It's insanely long...

As an academic physician at UCSD, I was disappointed to see the proposed Dress and Appearance Policy, MCP 559.2. I generally support the goals of professionalism (including in appearance), improved patient care, and patient satisfaction. Unfortunately, I find the specifics of the proposed policy somewhat arbitrary and potentially discriminatory. I have detailed my concerns below. I realize that this may seem lengthy, but I feel this is a very complex topic, and concerns the core values of an academic medical center such as UCSD. I apologize for not giving input earlier – an email I received 10/22 was the first time I was aware that such a policy was being advanced to this extent. I admit this may have been my own oversight.

1) Regarding Professionalism

a) Multiple Professions. There are many definitions of professional/professionalism in the business and medical literature. Merriam-Webster defines professionalism as “the conducts, aims, or qualities that characterize or mark a profession or a professional person”. While we share a common goal of patient care, the policy as written would cover a wide variety of professions, including physicians, nurses, social workers, case managers, and janitorial staff, all with different characteristics. Such a broad policy is unlikely to optimize “professionalism” for all these employees.

b) Physician Professionalism. The term professionalism is used throughout the abstract and policy, but it is not defined, at least in this section. In definitions used in the medical field, attire is rarely addressed. The Medical Professionalism Project took great lengths to define medical professionalism, including 3 charter values (primacy of patient welfare, patient autonomy, and social justice) and ten commitments, none of which focus on dress or appearance. (Medical Professionalism in the New Millennium: A Physician Charter. Annals of Int Med. (2002). 136(3). pp. 243-246.)

i) This need not mean that dress and appearance cannot affect professionalism, but that they should be viewed through the various values and commitments. In a broad sense, whether dress and appearance are “professional” is best judged by how they affect the therapeutic relationship or represent a direct risk to patients – not by what “first impression” they make. It should also be noted that dress and appearance are not interchangeable, and the differentiation can be important.

ii) With regard to the therapeutic relationship, dress and appearance are both subjectively judged by the patient in question, and can be thought of together. Optimizing the therapeutic relationship allows few absolutes, as can be demonstrated by the variety in the UCSD patient population. Anecdotally, I have had patients pointedly wonder why I do not wear a tie, and others express that they felt comfortable with me because I wear jeans or earrings. Neither type of patient is more important than the other, and no rules should be made that slants appearance in one direction or the other. For fiscal reasons, it may be tempting to err on the side of the patient of a higher socio-economic status, a decision that would truly be unprofessional.

With regard to one reference noted by the human resources staff, (Am J Med. 2005 Nov;118(11):1279-86) it should be noted that the data collected was from an outpatient setting with a demographic and educational mix that may not accurately reflect the population of Hillcrest or La Jolla. Further, it was judged by viewing pictures that did not address many of the specifics of the proposed policy. Other studies have shown no effect of attire on patient satisfaction. (Am J Obs and Gyn. 2007 Feb; 196 (2): 186)

iii) Direct Risk

(1) With regard to specific impacts on direct risks, dress and appearance can be quite different. Dress, the actual clothing and accessories worn, can have a definable impact on patient risks and disease. Oddly, the policy is silent in some areas where more data exist, e.g., studies demonstrating that long sleeves, white coats, and neckties can carry bacteria. Though a defined link to patient outcomes is less clear, even the AMA has considered recommending against these articles of clothing. The portions of the dress policy that address statutory issues, e.g., ID badges, or other known risks, e.g., hair covering in food areas, may be data driven and likely appropriate. Sections that ban specific fabrics seem less so.

(2) Appearance does not have such a direct impact on health care as infectious risk. Rather, the health impact of appearance would be related to a patient’s subjective assessment of that appearance, and the effect that a negative feeling might have on a patient’s trust or satisfaction. Such effects may well impact health outcomes, but can be hard to quantify. These concerns are not to be neglected, but do represent a slippery slope toward discrimination (see next section). It is therefore appropriate to weigh such an effect against the judgments of other patients, the rights of workers, and the value of diversity and free expression.

2) Concerns for Discrimination

a) The concerns listed in the abstract regarding patient trust, confidence, and satisfaction are appropriate. Efforts should be made to address them, especially when such concerns are objective, data driven, or can be alleviated without impinging on other goals. What constitutes appropriate/professional dress and appearance, though, is subjective and variable, and often represents a summation of the patient’s life experience. Unfortunately, this may include implicit and explicit discrimination or bias.

i) For instance, would UCSD indulge a patient who demanded a Caucasian physician as opposed to an African-American (or Latino or Asian), a male physician as opposed to a female, or a physician from a wealthy as opposed to poor family? Would we allow a patient to dismiss a homosexual or transgender physician? Would we make a staff member take off a Star of David for an anti-Semitic patient? Hopefully, the answer is a resounding “NO!”

ii) The line between the overt discrimination in (2)(a)(i) and the proposed policy’s attention to issues of patient trust, confidence and satisfaction is a fine one, and the slope is slippery. Many of the specifics of the policy do little more than validate less overt forms of discrimination based on age, gender, and culture. Tattoos cannot harm a patient, so why does the proposed policy demand they be covered? Tattoos are currently accepted in many cultures, particularly Asian/Pacific Islander, and are gaining acceptance in the US as a whole, particularly in the youth and LGBT communities. If a tattoo decreases a patient’s confidence in their physician or nurse, it is likely because the patient has subtle biases about people, or cultures, that tattoo. Why should this be indulged by policy, when we presumably would NOT accede to a patient’s request to not be treated by Hawaiian or LGBT staff?

iii) The variability in patient preferences is alluded to in (1)(b)(ii). In this regard “Professionalism”, like beauty, is in the eyes of the beholder; what is concerning or offensive to some may be encouraging or calming to others. It is not clear how the specific elements of dress and appearance addressed in the proposed policy were generated. It is possible that a few may be issues overwhelming addressed on patient surveys, and it may be reasonable to give these extra consideration. Regardless, it is important to consider that discrimination and intolerance are wrong, even by majority vote. Similarly, some axioms are true, if trite: the squeaky wheel does get the grease, and the plural of anecdote is not data. For every patient complaint about an element of dress, there may be an equal number or more people who were comforted by that element who were not asked about it.

b) The following examples illustrate some of concerns regarding patient variability and discrimination:

i) Example – Patient Variability: “Extreme hair colors should be avoided.” Consider an employee who dyes part of their hair blue and yellow for a Chargers game. This is not uncommon in San Diego. Some may consider this inappropriate for the hospital atmosphere. Some consider it a pleasant diversion, forging a bond that enhances comfort and the therapeutic relationship. And some may simply root for another team. Similarly, a female nurse with a shock of pink hair might frighten an older patient and amuse a younger one. Neither reaction is objective, or superior, or more important.

ii) Example – Gender Roles: “Shorts…are not appropriate in a professional setting.” What is the difference between a male case manager wearing shorts that come to the knee, and a female wearing a skirt of similar length? Both expose the professional’s lower legs. Neither is dangerous to the patient. If the basis of acceptability is that one is a man and the other a woman, then the root is an expectation/assumption of gender expression, which is somewhat discriminatory. Would the male employee be considered more professional in a skirt than in shorts? Remember, it was not long ago that a female wearing pants was considered unprofessional. Secretary Clinton might argue that there are 17 million cracks in that point of view.

iii) Example – Socio-Economic Bias: “…denim of any type and similar casual clothes are not appropriate in a professional setting.” Denim is a sturdy and easily washed fabric made from 100% cotton. Why is it less professional than other fabrics made from 100% cotton? Many believe the “professional” taboo against denim is rooted in the fact that it was traditionally worn by farmers and manual laborers, who needed an inexpensive fabric that was durable. Others believe it related to the youth movement of the 1960s. Regardless, it was judged inappropriate for occupations of “higher” socio-economic status. In an age where environmental sustainability is important, at a hospital where staff wages are being cut, in a profession where bodily fluids are a common hazard – what is unprofessional about a durable, easily cleaned fabric? Only deep-rooted socio-economic biases.

Consider other fabrics. Silk might be “professional” to most in a tie, inappropriate as lingerie, and arguable in a male’s work shirt – does he look impressive, or like a “gangster”? Leather is almost universally appropriate as a belt or in shoes. Many would argue leather pants on a male would be inappropriate, yet few males who own them would consider them “casual”. What about a leather skirt from a female employee? In red? There is really no reason to universally dismiss a fabric – if there is a legitimate concern, it more likely relates to a more specific piece of clothing.

iv) Example: Religion vs. Culture -- Nasal piercings can be a religious adornment for Hindu women. They have also become a cultural affectation for women of Asian Sub-continental cultures, regardless of specific religion, and have gained broader popularity in America. They are banned by the proposed policy, with an exception for religion. Is religious expression particularly definable and more important than cultural expression? Who will judge religious devotion versus cultural expression? What about a paganist’s religious eyebrow piercing? A gay persons cultural expression by piercing?

v) Example: Complexity of issues – culture, variability, risk assessment. “Tattoos or other types of body art must be covered by clothing, a band-aid, make-up, etc.” The cultural issues regarding tattoos are discussed briefly in (2)(a)(ii). In a more specific example, consider health care employees who get their start in the military, where tattoos are common. A patient with a military tattoo on their forearm might unsettle some patients. Other patients, especially but not only veterans, might be comforted or identify with a veteran staff member. To comply with the proposed policy, the staff member would have to cover this tattoo. The simplest way to do so would be to wear a long sleeved shirt or coat. This action would satisfy the unsettled patients concerns, at the expense of the comforted patient. With regard to patient satisfaction, this yields no overall benefit, except that the unsettled patient may be more likely to complain about the tattoo than the comforted patient is to mention it in a positive way.

Further, the compliance action, a long sleeved shirt, may put both patients at risk of infection, a negative effect that should outweigh even a benefit to subjective satisfaction.

c) To be clear, there are reasonable policy issues regarding dress, and there may be some regarding appearance. But they should be limited to definable risks, and things that are specifically objectionable or offensive. For instance, it may appropriate to ask an employee with a Swastika or vulgar phrase to cover it, as this is more about avoiding a direct offense than indulging in a subtle bias. Such an “I’ll know it when I see it” policy is not easy to monitor or enforce, but it is better than indulging discrimination or unnecessarily stifling free expression.

3) Why not UCSD Medical Center? The arguments above can be made, and likely have been, at any institution considering a policy on dress and appearance. Despite this, many businesses have such a policy. It is reasonable to ask why UCSD Medical Center should be different.

a) As this relates to “Professionalism”, not all occupations are considered professions. The difference can be semantic, but given the reliance of the proposed policy on the idea of “Professionalism”, it seems germane. One way to express the difference is that professions, like medicine or health care, involve a fiduciary responsibility to the client. (http://depts.washington.edu/bioethx/topics/profes.html) In other words, we have obligations to work to benefit ALL our patients, even at a potential cost to us. While this is not unlimited, it differs from a business. A retail store might endorse a profitable policy that pleased a majority of clients, or a minority of high paying clients, even if other clients suffered. For a profession, such as health care, this is NOT appropriate; we have a duty to all patients that goes beyond profit.

b) The prior argument explains why the policies of other businesses might not apply to UCSD Medical Center. But what about the dress and appearance codes of other hospitals?

i) UCSD is different. It is an academic institution, and is committed to the largely unfettered pursuit of knowledge. Especially in recent years, academia has become the place where diversity and free expression are valued the most. The American Association of University Professors highlights the importance of academic freedom as follows:

"Institutions of higher education are conducted for the common good and not to further the interest of either the individual teacher or the institution as a whole. The common good depends upon the free search for truth and its free exposition" (http://www.aaup.org/AAUP/issues/AF/)

ii) It is governed by the Great State of California, which has strict policies against discrimination based on (but not limited to) the following: race, sex, religion, sexual orientation, age, and national origin (State of California, Department of Fair Employment and Housing). In its mission statement, UCSD underscores this commitment to fairness and non-discrimination:

“To foster the best possible working and learning environment, our university strives to maintain a climate of fairness, cooperation, and professionalism, which is embodied in our campus Principles of Community. UC San Diego embraces diversity, equity, and inclusion as essential ingredients of academic excellence in higher education.” (http://www.ucsd.edu/explore/about/)

Clearly, UCSD’s mission includes professionalism, but not at the expense of diversity, equity, and inclusion. Indeed, the idea of indulging subtle discrimination at a teaching institution like UCSD is particularly troubling – not only does it validate those espousing such biases, but it risks teaching our trainees that such discrimination is acceptable.

iii) The Core Values of UCSD Medical Center are equally clear:

“Caring: Commitment to valuing differences and respecting the well-being and dignity of each person.” (health.ucsd.edu/about/mission.htm)

Notably, UCSD’s policy does not specify each patient, but each PERSON, suggesting that the commitment to valuing differences extends to all people at UCSD, both patients and employees.

c) In short, a business might pursue any dress and appearance code they found profitable. A profession, like medicine, must consider the best treatment of each patient above the wishes of a majority, and above any related concerns for profit. As an academic center, UCSD, by it’s own mission and the goal of academics, must weigh the importance and benefits of diversity and free expression, and the danger of teaching discrimination, when considering such a policy.

d) To maintain its excellence, UCSD must recruit and maintain medical students, residents, and faculty. All of these groups would be affected by this policy, and some may choose to leave rather than be part of a discriminatory institution. It is also notable that many of the articles banned by the policy (facial piercing, tattoos, denim, hair color) are increasingly popular and accepted in the young people we will need to refill our professional ranks. With that in mind, our policy should be on the side of openness and diversity to ensure long-term excellence. It would be sad to lose our ability to recruit the best and brightest nurses and doctors of tomorrow because of a policy based on biases of today.

e) There is also an issue of logistics, largely for physicians. At an academic center, many physicians work by pager, coming from clinics, laboratories, or home. Should a physician stop to change clothes if paged while wearing jeans, or without his or her tattoo covered? Most patients and families would presumably be more concerned about when the doctor arrived than what he or she was wearing.

4) Summary

This does not mean there is no room for a policy on dress and appearance, but it must be fair to all patients, and limited to data driven interventions that prevent definable harms, such as bacterial contamination or risk of injury. It must not arbitrarily impinge on free expression or indulge discrimination based on gender, culture, age, or sexual orientation. Sadly, too much of the proposed policy focuses on the latter, occasionally at the expense of the former.

Thank you for your kind consideration. I would be honored to meet with the committee or its members to further discuss these issues, especially any policies that are driven by outside research or significant data that has been obtained from our patients.