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Doctor’s attire influences perceived empathy in the patient–doctor relationship
Heesu Chung, Hyeyeon Lee, Dong-Seon Chang, Ho-Sun Kim, Hyejung Lee, Hi-Joon Park,
Acupuncture & Meridian Science Research Center, Kyung Hee University, Seoul, Republic of Korea
Communication is a crucial component in establishing a
positive patient–doctor relationship and various studies have
indicated its importance by demonstrating a close association
between patient–doctor communication and direct patient health
outcomes [1–4]. However, there are various forms of interactions
during a clinical encounter which can determine the patient–
doctor relationship  and few studies have attempted to analyze
the different components of patient–doctor communication
separately . Although the verbal component is essential to
share important medical information with the patient and enhance
‘patient enablement’ , nonverbal behavior has received surpris-
ingly little attention in the field of health communication [8,9].
Non-verbal behavior encompasses physical appearance, gesture
and body movements, facial expressions, eye movements and
vocal modifications [10,11], whereas during the first clinical
encounter, the physical appearance of the doctor plays an
important role for establishing the subsequent patient–doctor
The doctor’s attire is a vital part of the first impression the
patient will develop of the doctor . During the first clinical
encounter, the patient and the doctor do not only exchange
medical information about the treatment, but also build up trust
and confidence for the future therapeutic relationship [12,14]. The
attire or clothing in general is an influential source of nonverbal
communication , especially in the absence of other informa-
tion about the person such as during the first encounter . For
physicians, the doctor’s attire functions as a symbol of recognition,
professionalism and trust [17,18], whereas in other professions,
the attire or clothing style also functions as a message source of
nonverbal communication on credibility, trustworthiness, or
likeability [19,20]. It has been also reported, that dressing more
formally in workplaces results in more professional behaviors and
changes in self-perceptions of the employees [21,22]. However, the
doctor’s appearance is not the only factor influencing the patient-
doctor relationship. There are a number of non-specific and
psychosocial factors which have been known to play a great role in
patient satisfaction and improvement, and along with the different
expectations of the patients, the doctor’s physical appearance in
the patient-doctor relationship is just one of those factors [23,24].
It has been also known, that patients, who particularly seek
Patient Education and Counseling 89 (2012) 387–391
A R T I C L E
I N F O
Received 2 March 2011
Received in revised form 23 February 2012
Accepted 26 February 2012
A B S T R A C T
Objective: This study investigated whether doctors’ attire influences the perception of empathy in the
patient–doctor relationship during a therapeutic encounter.
Methods: A total number of 143 patients were divided into four groups when they were consulting a
Traditional Korean Medicine doctor. Depending on the group, the same doctor was wearing four different
attires – Casual, Suit, Traditional dress, White coat – when having a clinical consultation with the
Results: The patients preferred white coat and traditional dress more than other attires, giving highest
scores to white coat in competency, trustworthiness and preference of attire and to traditional dress in
comfortableness and contentment with the consultation. The ‘‘Consultation and Relational Empathy
(CARE)’’ score was significantly higher in the ‘‘White coat’’ and ‘‘Traditional’’ groups, compared to the
‘‘Casual’’ and ‘‘Suit’’ groups.
Conclusion: The strong association between the patients’ preference of doctors’ attire and the CARE score
indicates that the doctor’s attire plays not only an important role for establishing confidence and
trustworthiness but also for the perception of empathy in the patient–doctor relationship.
Practice implications: The doctor’s attire can function as an effective tool of non-verbal communication in
order to signal confidence, trust and empathy and establish a good patient–doctor relationship.
? 2012 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Acupuncture & Meridian Science Research Center,
Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republic of
Korea. Tel.: +82 2 961 2208; fax: +82 2 963 2175.
E-mail address: email@example.com (Y. Chae).
Contents lists available at SciVerse ScienceDirect
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0738-3991/$ – see front matter ? 2012 Elsevier Ireland Ltd. All rights reserved.
Author's personal copy
alternative treatments such as acupuncture, seem to value the
relationship with their practitioner very high [25,26].
Empathy is also a fundamental and crucial component in
establishing a good therapeutic relationship between a patient and
a doctor [27,28]. Empathy in a therapeutic relationship can be
defined as following: empathy in the clinical context involves the
ability (1) to understand the patient’s situation, perspective and
feelings (and their attached meanings); (2) to communicate that
understanding and check its accuracy; and (3) to act on that
understanding with the patient in a helpful therapeutic way . A
measure of empathy assessing patients’ perception of the
practitioner’s empathy in the clinical encounter was developed
by Mercer et al. This assessment has been called the ‘consultation
and relational empathy’ (CARE) measure and has been tested and
validated in several contexts . The CARE measure is considered
as being of high relevance to everyday consultations in general
practice by both practitioners and patients .
There have been many studies about the influence of different
doctors’ attire on patients’ perception of competency or trust
[13,17,32–35]. However, the question whether the doctor’s attire is
also associated with the establishment of more empathy in the
patient–doctor relationship has not been answered yet. In
addition, most of the previous studies on the influence of doctors’
attire were carried out showing the patients different photographs
of the doctor, but not tested in real clinics [32–35].
In the present study, we assessed the possible association
between doctors’ attire and empathy in a therapeutic relation-
ship using the CARE measure. We hypothesized that higher
ratings of traits such as competency, trustworthiness and
preference for a certain dress style should be in compliance
with more perception of empathy in the therapeutic relationship
for the same attire, and tested this not in an experimental setup
but in real clinics.
2.1. Participants and groups
A total of 143 patients (male = 48, female = 95) participated in
this study. All patients were recruited at a Traditional Korean
Medical Clinic in Kyunggido, Korea. Only patients were recruited
who visited the clinic for the first time in order to control for
prejudgments of the patients toward the doctor. Additionally, only
patients were recruited who came for the treatment of pain by
acupuncture in order to control for symptoms and treatments.
Basic demographic data such as name, age, and gender were
acquired from all participants by a questionnaire. This investiga-
tion was conducted in accordance with the guidelines of the
human subjects committee of Kyung Hee University, Seoul,
Republic of Korea.
The patients were randomly divided into four different
groups and the same doctor met the patients in four different
attires during the first clinical consultation. The first group
male = 17,
female = 21)
wearing Casual, whereas the second group (‘‘Suit’’; male = 8,
female = 24), third group (‘‘Traditional’’; male = 10, female = 25),
fourth group (‘‘White coat’’; male = 13, female = 25) were seeing
the same doctor wearing Suit, Traditional dress and White coat,
The clinical consultation between the doctor and the patient
always followed the same order and process. The consultation took
about 5 min per patient and proceeded as following: (1) Asking
about the main complaint and pain (the location of pain, when did
it start, how does it feel), (2) feeling the pulse for diagnosis, (3)
palpation of the location of pain, (4) stating the doctor’s diagnosis
(5) teaching matters that require attention during the time of the
treatment and after the consultation.
2.3. Patient evaluation after consultation
After the consultation, the patients were asked about their
impression of the doctor’s competency, trustworthiness, comfort-
ableness, preference of attire and their contentment with the
consultation by an independent experimenter. These five ques-
tions were asked in a questionnaire and the patients had to answer
using a 5-point Likert scale, whereas 5 represented ‘‘strongly
agree’’, 4 ‘‘agree’’, 3 ‘‘neither agree nor disagree’’, 2 ‘‘disagree’’ and 1
The independent experimenter also assessed empathy in the
therapeutic relationship using the ‘Consultation and Relational
Empathy’ (CARE) measure. This questionnaire was developed by
Mercer et al. in order to have a general consultation process
measure which assesses empathy in a therapeutic relationship
. This questionnaire consisted of 10 questions with possible
answers on a 1–5 scale. For the measure, the answers to all
questions were added together, whereas the total achievable score
2.4. Data analysis
The answers about the patients’ impression of the doctor
and the CARE measurement scores after the consultation
were analyzed using a one-way analysis of variance (ANOVA)
and Tukey’s post hoc analysis. For statistical analysis, SPSS 13.0
was used and the statistical significance level was set for
p < 0.05.
3.1. Demographic characteristics
The sample population comprised of hundred and forty three
(143) outpatients, with the mean age of 37.7 years. The ‘‘Casual’’
group consisted of 38 patients, 17 male (45%) and 21 female (55%),
with the mean age of 36.8 years. The ‘‘Suit’’ group consisted of 32
patients, 8 male (25%), 24 female (75%), the ‘‘Traditional’’ group
consisted of 35 patients, 10 male (29%), 25 female (71%), and the
‘‘White coat’’ group consisted of 38 patients, 13 male (35%), 25
female (65%), with mean ages of 38.8, 38.1 and 37.1 years,
3.2. Group differences
There was a clear difference between the ‘‘Traditional’’ and
‘‘White coat’’ group, compared to the ‘‘Suit’’ and ‘‘Casual’’ group,
when patients’ impressions of the doctor after the clinical
consultation were evaluated by five different questions regarding
the doctor’s competency, trustworthiness, comfortableness,
preference of attire and the contentment with the consultation
(Table 1). To question 1 ‘‘the doctor seemed competent’’, question
2, ‘‘the doctor seemed trustworthy’’, and question 4, ‘‘I prefer this
doctor’s attire’’, the doctor got highest ratings from the patients in
the ‘‘White coat’’ group, followed in the order of ‘‘Traditional’’,
‘‘Suit’’, and ‘‘Casual’’ groups. The doctor got higher ratings from the
‘‘Traditional’’ group to question 3, ‘‘the doctor made me feel
comfortable’’, and question 5, ‘‘I am content with the consulta-
tion’’, followed in the order of ‘‘White coat’’, ‘‘Suit’’, and ‘‘Casual’’
H. Chung et al. / Patient Education and Counseling 89 (2012) 387–391
Author's personal copy
3.3. Assessed empathy in the patient–doctor relationship
The patient–doctor relationship was evaluated using the
‘‘Consultation and Relational Empathy (CARE)’’ measurement
questionnaire [7–9]. When all patients’ answers were evaluated
and averaged, there was a significant difference between the
‘‘White coat (38.29 ? 0.98)’’ and ‘‘Traditional (37.72 ? 1.32)’’ groups
and the ‘‘Casual (33.65 ? 1.24)’’ and ‘‘Suit (33.85 ? 0.80)’’ groups
[F[3,139]= 5.451, p < 0.001]. The CARE score was significantly higher in
the ‘‘White coat’’ and ‘‘Traditional’’ groups, compared to the ‘‘Casual’’
and ‘‘Suit’’ groups. The ratings to all ten questions were averaged and
a total CARE measure score was determined for each group as shown
in Fig. 1.
4. Discussion and conclusion
What is the relationship between the first impression of a
doctor, and perceived empathy in the therapeutic consultation
with the doctor? For sure, it is to be expected that a good first
impression should lead to more empathy felt in the therapeutic
relationship. However, the answer to this question depends very
much on what determines the first impression of a doctor. First
impressions, including inferences of specific personality traits such
as attractiveness, competency, trustworthiness, or likeability are
known to be formed fast, intuitive and unreflective, even within a
few hundred milliseconds . These first impressions in general,
not only in specific social situations, are predominantly formed by
the intuitive recognition of facial features [36–39], but it has been
also reported that clothing cues play a significant role in predicting
people’s general impression of a person . In the present study,
we tried to control the first impression of a medical doctor during
the first clinical encounter with the single independent variable of
the doctor’s attire. The same doctor met four different groups of
patients and went into the first clinical consultation session
dressed in four different attires – White coat, Traditional, Suit and
Casual, respectively. Since the doctor was the same, and followed
the exact same protocol in each session, there could be no
significant difference in facial features or verbal communication
When the patients were asked to rate their first impression with
the doctor, they gave highest scores in ‘competency’, ‘trustworthi-
ness’ and ‘preference’ when the doctor was dressed with the white
coat, and highest scores in ‘comfortableness’ and ‘contentment
with the consultation’ when the doctor was dressed ‘Traditional’.
These results are in concordance with our previous study ,
where we asked the patients the same questions with the only
difference that the patients did not actually meet the doctor but
rated pictures of a doctor in four different attires (White coat,
Traditional, Suit and Casual) on a computer screen, in a controlled
experimental setting. The impact of clothing cues on the formation
of first impression and trait inferences of the doctor seem to be
consistent, regardless of whether this cue was presented in a real
clinical session or in a virtual, experimental setup.
Our results are also consistent with other studies, reporting
higher scores in trustworthiness and confidence ratings for doctors
wearing the white coat [17,32,33,41–43]. However, considering
the recent discussions about the dangers of hospital infections due
to the white coat, especially in the UK, and the negative
connotation of the ‘white-coat effect’, the results could be different
depending on where this kind of study was conducted [44–47]. The
social perception of the doctor in patients differs from society to
society . In Korea, even though oriental medical doctors have
been practicing healing in traditional dresses for more than
2000 years, the white coat nowadays symbolizes predominantly
‘scientific’ and ‘professional’ medical settings, which is why the
white coat is associated with positive images in patients . Still,
it has been also shown that patients feel more comfortable and
content when the doctor treated them in the traditional dress. This
could be due to the fact that this study was conducted in a
Traditional Korean clinic.
In our present study when comparing different groups of
patients, the patients’ evaluation of the doctor’s traits depending
on the doctor’s attire was notably overlapping with the total CARE
measure score. The CARE measure score was the highest for the
white coat and traditional dress. This suggests an influence of
doctor’s attire on the establishment of empathy in the therapeutic
situation. Previous studies have revealed that the practitioner’s
empathy was indeed related with the answers of patients and that
the CARE measure is a valid tool to assess this . The validity of
the CARE measure was also proved in different cultures, including
England and China [31,49].
Fig. 1. The patient–doctor relationship was evaluated using the Consultation and
Relational Empathy (CARE) measurement questionnaire. The CARE score was
significantly higher in the ‘‘White coat’’ and ‘‘Traditional’’ groups, compared to the
‘‘Casual’’ and ‘‘Suit’’ groups. Data are represented as mean ? S.E.
Patients’ evaluation of doctor’s attire after the clinical consultation.
Casual (n = 38)
Suit (n = 32)
Traditional (n = 35)
White coat (n = 38)
‘‘The doctor seemed competent’’
‘‘The doctor seemed trustworthy’’
‘‘The doctor made me feel comfortable’’
‘‘I prefer this doctor’s attire’’
‘‘I am content with the consultation’’
3.42 ? 0.12
3.63 ? 0.15
3.55 ? 0.14
3.61 ? 0.10
3.66 ? 0.12
3.59 ? 0.12
3.69 ? 0.31
3.66 ? 0.14
3.53 ? 0.12
3.75 ? 0.14
3.94 ? 0.15**
3.97 ? 0.11
4.09 ? 0.14**
3.94 ? 0.16
4.11 ? 0.13**
3.97 ? 0.10**
4.13 ? 0.09**
4.05 ? 0.12**
4.08 ? 0.11**
4.11 ? 0.10**
**p < 0.01 compared with Casual.
H. Chung et al. / Patient Education and Counseling 89 (2012) 387–391
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How does the preference for the white coat and traditional
dress relate to more perceived empathy in the clinical consulta-
tion? Probably the answer lies in the patients’ expectation. The
patient–doctor relationship is often determined by whether the
doctor’s actual image including his/her verbal and nonverbal
behavior is concordant with the patient’s own expectation of the
doctor’s image [6,50]. Health care outcomes often include the
component of patient satisfaction and since the patients’ ratings of
these values are mainly subjective, positive results are often
related to the factor of how much the doctor’s image goes together
with what the patient expects . In turn, the doctor’s verbal and
nonverbal communication behavior must also often go together
with what the doctor thinks that the patient expects [52,53]. This
way, the perceived empathy in the clinical consultation as a main
factor of establishing a positive patient–doctor relationship is
probably also closely associated with the patient’s expected image
of the doctor.
There are a number of limitations of this current study which
should be mentioned. First, in this study, only one doctor and one
clinic was used in this setting, therefore the meaning of the results
of this study could be limited by the socio-cultural surroundings
where this study has been carried out. Second, the gender of the
doctor (female) could have an influence on the ratings of the
patients. If possible, in future studies the gender of the doctor and
the patients should be balanced and controlled. Third, there is the
possibility that the self-perception and preference of the doctor for
the attires have played a role and influenced impressions of the
patients. Still, this possibility can be ruled out by looking at the
results of the previous study where this was controlled .
In summary, we hypothesized that higher ratings of traits such
as competency, trustworthiness and preference for a certain dress
style should be in compliance with more perception of empathy in
the therapeutic relationship for the same attire, since higher
ratings of the patients should reflect whether doctor’s attire was
concordant with the patients’ expectation of the doctor’s appear-
ance. The higher scores in ‘competency’, ‘trustworthiness’ and
‘preference’ when the doctor was dressed in the ‘white coat’, and
‘comfortableness’ and ‘contentment’ when the doctor was dressed
‘traditional’, went together with the higher total CARE scores for
the doctor dressed in ‘white coat’ and ‘traditional’. The similar
ratings of the patients’ preference of doctors’ attire and the
perceived empathy in the patient–doctor relationship indicates
that how the doctor is dressed has an effect in establishing a good
patient–doctor relationship and confirms our hypothesis.
4.3. Practice implications
Making a good first impression in clinical encounters is not only
important for building up trust and confidence, but also for
enhancing perceived empathy which is in turn important for the
therapeutic relationship. It could be advisable to dress according to
the patients’ expectation of the doctor’s image, which would be
preferably wearing a white coat or a traditional dress for a clinical
consultation in Korea. In general, educating practitioners about
how their attire or clothing functions as an influential source of
nonverbal communication would be also an important matter for
enhancing the patient–doctor relationship.
Conflict of interest
None of the authors have any conflicting of competing interests
regarding this article.
Author disclosure statement
The authors declare that no competing financial interests or
conflicts of interest exist. The funders had no role in the study
design, data collection and analysis and the decision to publish the
Role of the funding source
None of the authors have any role of the funding source
regarding this article.
This research was supported by Basic Science Research Program
through the National Research Foundation of Korea (NRF) funded
by the Ministry of Education, Science and Technology (No. 2005-
0049404). The first author, named by Heesu Chung, was supported
by the Undergraduate Research Program (URP) grant funded by
Kyung Hee University College of Oriental Medicine. We also thank
Hunter Desmaray for his help in editing and proofreading the
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