By Mr. Lawrence Toquero , Mr. Omar Aboumarzouk , Ms. Corinne Owers , Dr. Ryan Chiang , Mr. Shankar Thiagarajah , Mr. Shwan Amin
Corresponding Author Ms. Corinne Owers
Sheffield Teaching Hospitals, - United Kingdom S10 1QY
Submitting Author Dr. Corinne Owers
Other Authors Mr. Lawrence Toquero
Department of General Surgery, Northern General Hospital, - United Kingdom S5 7AU

Mr. Omar Aboumarzouk
Department of General surgery, West Wales General Hospital, Dolgwili Road, Carmarthen, SA31 2AF, UK, - United Kingdom

Dr. Ryan Chiang
Department of General Surgery, Northern General Hospital, - United Kingdom

Mr. Shankar Thiagarajah
Department of General Surgery, Northern General Hospital, - United Kingdom

Mr. Shwan Amin
Department of General Surgery, Northern General Hospital, - United Kingdom


Bare Below Elbows, Patient Preference, Doctor's Appearance

Toquero L, Aboumarzouk O, Owers C, Chiang R, Thiagarajah S, Amin S. Bare Below The Elbows- The Patient's Perspective. WebmedCentral QUALITY AND PATIENT SAFETY 2011;2(4):WMC001401
doi: 10.9754/journal.wmc.2011.001401
Submitted on: 21 Apr 2011 04:05:04 AM GMT
Published on: 21 Apr 2011 02:15:11 PM GMT


Introduction and Aim: In recent times, the department of heath has implemented new policies with regards to doctors’ dress code in order to try and control infection rates. Patient confidence, and trust in doctors, is as equal to receiving treatment itself. Since the end of the ‘formal dress: shirt and tie’ era, the view point of the patient has not been evaluated. We aim to illicit the patients perspective on this issue.
Method: A prospective study using a questionnaire to analyse the perspective of all patients admitted on the new department of health policy.
Results: only 14% of patients were aware of the new policy. 61% of patients say appearances do matter to them, 75% did not believe the attire would affect their level of care, and 95% of the patients have complete confidence despite doctors’ appearances. The majority of patients preferred their doctor to be in a shirt and tie, as they felt Doctors would look more professional that way.
Conclusion: There is no conclusive evidence to support the department of health’s policy on ‘bare below the elbow’. Patients have an image of the ideal doctor and feel more comfortable with that idea. Non the less, patients trust and respect health professionals regardless of their attire, even if they do not agree with it.


On September 17, 2007, the Secretary of State for Health, issued a press release which contained a promise to introduce a range of measures in NHS hospitals including a ‘bare below the elbows’ dress code for those involved in clinical activity in all acute trusts.1 This followed a widely publicised outbreak of MRSA and Clostridium Difficile in which various demands and claims were made on the regulation of a dress code to help improving hospital infection control.2 All hospitals were asked to implement the new policy of bare below the elbow starting, January 2008.1
The Department of Health’s policy was supported by a publication that provided the basis of the decisions.3 The paper also summarised some of the evidence used to base the new policy.3 The paper outlines guidance for employers and employees on uniform dress code, laundry practices, and hand hygiene.3
The report has been much maligned by both the medical profession and the patient body, which lead to major criticism due to the lack of scientific evidence on which the Department of Health based its policies.2 The British Medical Association (BMA) felt the policy was issued hastily in response to an intense period of media focus on the issue.2
The primary aim of the policy is to try to reduce the spread of hospital infections with bacteria like MRSA and C. Difficile. However, there is no evidence published to support a relationship between a ‘bare below the elbows’ dress policy and a reduced hospital acquired infection rate.
Though this issue is under great scrutiny, a different view of the ‘bare below the elbow’ dress code is the image of the Doctor. Though, not a point in the GMC’s good medical practice article; a great deal of doctors believe it reduces the patients’ trust and confidence in them, due to lack of professionalism.4
To this end, a prospective study was conducted to evaluate whether or not patients believe the manner in which doctors’ dress affects the quality of healthcare they are receiving, if their confidence in doctors is affected by how they dress, and whether or not a doctor’s attire is important to patients. Finally, a survey of whether or not patients were aware of the new policy and why it is being implemented across the country was analysed.


A prospective study using a patient questionnaire was devised to assess the patients’ perspective of the new dress code policy which has been implemented in the general hospital for over 6 months. The study was conducted with the support of the Ethics committed and the service evaluation department at the hospital.
During the month of June 2008, all electively and acutely admitted patients to the general surgical and orthopaedic wards were asked to participate in the study by filling in the questionnaire. To minimize the risk of bias, the ‘Bare Below the Elbows’ policy was explained from the original department of health document and a copy was given to each patient along with the questionnaire and a pre-paid envelope. The patient was given the option of either handing in the questionnaire before discharge or to post it, reducing any chance of influence which might alter the patient’s decisions.
All patients who were admitted were included in the study with no exclusions. The questionnaire included patient demographics, questions on whether or not the patient new and understood the department of health’s new policy, questions on the patients perspective and view points of doctors’ attire, questions on whether the patients believed that what doctors wear had any affect on their level of care, and whether or not the patients witnessed their attending doctor wash their hands or use alcohol gel.


The evidence the department of health is using, which they state is an evidence-based document, is based on a review conducted by the Thames Valley University, named TVU1 and TVU2.3, 5 The TVU1 review looked at the role of uniforms in the transfer of infections and the efficacy of laundry practices in removing contaminations, while TVU2 looked at how uniforms might affect the image of the individual and the organisation by which they work for.5 In addition the department states other sources for their evidence such as a research conducted by University College London Hospital, on washing material at different temperature to remove deliberate contaminations.5 Though, the reviews and research are not published yet, the department of health claim they ‘will be’ published in scientific journals, and would provide a link for their evidence.3
Magee T, wrote a paper which thoroughly examined the department of health document and policy and came up with derogatory points for each statement the department of health put forward.5 Dehn T, has also studied the policy brought by the department of health, but took it a step further by writing to Professor Lord Darzi of the department of health, asking for evidence-based articles supporting the bare below the elbow policy, but he had not received any replies.5 Hence, the policy was submitted and put in to action based on unpublished, unproven, inconclusive evidence that doctors’ attire poses any significant risk of spreading infections.
In our study we looked at the patient’s point of view in this controversial topic. We found that the majority of patients with 86%, did not even know of the policy, while of the remaining 14% knew of it but not exactly of what it entails.
Working in the health services, we aim to treat our patients each as individuals. Since there is no conclusive evidence to prove that what we wear affects infection rates or controls infection, one must look at the professionalism of the policy. In our study we found that 63% of the patients thought that a shirt and tie are more suited for our profession as doctors, while 22% thought we should even dress more elegantly with suits and only a meagre 6% though a sleeveless shirt was professional and as one patient’s stated ‘cool’.
Still unshaken and undeterred, the patient’s confidence and trust in us doctors remained high despite out the ‘changing of clothes’.
In conclusion, there is no definitive evidence to support the department of health’s policy on ‘bare below the elbows’. Patients have an image of the ideal doctor and feel more comfortable with that perception. Non the less, patients trust and respect health professionals regardless of their attire, even if they do not agree with it.


1. Johnson A. Department of Health. Press statement.2007. p;NavigatedFromDepartment=True.
2. Guidance from the Central Consultants and Specialists Committee. Uniform and dress code for doctors. BMA 2007.
3. Department of Health. Uniforms and Workwear. An evidence base for developing local policy. London DH. September 2007. _078433
4. GMC. Good Medical Practice. GMC website 2006.
5. Magee TR, Dehn T. Bare Below the Elbows – difficile times for a health secretary. Ann R Coll Surg Engl (suppl) April 2008; 90:126-129.

Source(s) of Funding

Nil required

Competing Interests

None declared


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