By December 17, 2014 15 Comments Read More →

What’s Up With Neckties in Healthcare?

Willard L. MetcalfIt’s a simple question: what’s up with so many men wearing ties in healthcare? Are you / they wearing them because you like to, want to, or have to?

When I worked at a video game and computer software store in high school, I had to wear a shirt and tie. This was the era of the original Nintendo Entertainment System, Sega Genesis, and Windows 3.0. I also sold the original Windows 286 and Windows 386 systems. I’m old. I’m not sure how wearing a tie helped us relate to our customers, but that was the professional image the store wanted to convey, I guess. I didn’t find it comfortable, but we all put up with it.

I worked as a summer college intern for Ford two different summers and had to wear a shirt and tie. When I started working at General Motors in 1995 after graduation, they had JUST switched to a business casual dress code. I got to wear Dockers or dress pants with a polo shirt or button down shirt. I was happy. My industrial engineer manager and many others who had been there a long time were at a bit of a loss. They were used to wearing suits and ties, so they generally wore what they used to wear, minus the tie.

Our quality and productivity were terrible compared to Toyota. It wasn’t because we dressed more or less formally. Our performance was due to the management system, or lack thereof. I don’t think I would have respected the old school, blame-and-shame command-and-control managers any more if they had been wearing ties. I don’t think going back to suits and ties would have solved any “discipline” issues, as wrongly perceived by old-school management (they blamed workers and employees for our problems).

Suit and tie, or shirt and tie, was a tradition in the auto industry, as it was in many other workplaces. But, times change. For better or for worse, the United States is a much more casual country than it was 20 years ago (some time say “sloppy”). Beyond appearances and questions of comfort, neckties can be dangerous in factories, which a risk of strangulation that would occur if your tie got caught in moving machinery.

When I worked at different manufacturing companies and a previous software startup, I didn’t feel unprofessional without a tie. I learned that respect and professionalism were behaviors, not an appearance.

When I switched paths into healthcare in 2005, I was really surprised to see that the widespread “business casual” memo had not been circulated at most American hospitals. Even today, almost ten years later, I still see most men in shirts and ties: senior executives, directors, managers, process improvement staff. In some hospitals, every man, including transporters and housekeeping staff, wear shirts and ties.

Why? Because they’ve always done it that way? Is that really a reason to keep wearing them?

Personally, I find a shirt and tie to be uncomfortable and constraining. I also have a bit of an annoying congenital neck issue, two fused vertebrae, that often gives me a literal pain in the neck. I’m happier not wearing a tie. I’m fine wearing a suit or a sport coat without a tie. I’m not sure, sometimes, which is dressier – a shirt and tie without a jacket or a suit without a tie.

Sorry to go into so much detail… which brings me back to the main point and question: does more formal attire matter the least bit for healthcare quality, patient safety, respect in the workplace or other factors?

When I was in The Netherlands last month, I visited three different hospitals altogether and didn’t see a single person wearing a necktie. It didn’t seem the least bit unprofessional there, as people still take their jobs very seriously.

In 2006, England and its NHS banned long neckties (among other “superfluous” items for men and women, in the name of infection control. When I was a visiting consultant at an NHS hospital, it didn’t seem less professional than an American hospital. In 2013, some complained that “scruffy doctors” were creating problems in the NHS and that, for example, bans on white coats didn’t help infection rates.

Hmm… in the spirit of Plan-Do-Study-Adjust, we should look at data and evaluate changes. Did banning ties help? That might not be clear. Does wearing ties help? I’m not so sure how you would determine that. If wearing suits and/or ties somehow makes people look more respectable and more professional, should doctors and executives dress even more formally? Wouldn’t a three-piece suit look more professional? A top hat? Where would it stop?

Recently, I worked with a hospital client where most everybody wears ties. One vice president made a point of always wearing scrubs, because he thought that helped him fit in. He was trying to gain respect by NOT wearing a tie. Interesting. Again, I found him to be just as diligent, passionate, intelligent, and hard working as everybody else. I respected him because of his attitude, what he did, and what he said – not what he was wearing.

As a patient, my primary care physician is a woman, so ties aren’t an issue. She dresses professionally, but what I’d call the dressier side of business casual. She’s certainly not wearing formal women’s business suits. My opthamologist wears ties. My dentist dresses like I used to in manufacturing — dress pants and a button down shirt (with a white coat). I respect all of them. I’m impressed with the tie and I wouldn’t be turned off if they wore scrubs.

As a patient, I’m thinking about the value-added work and my own health, not what people are wearing. How about you?

How are things at your hospital? Do people justify and rationalize the formal attire for reasons other than habit and tradition? Are there voices that speak up about trying to be a little less formal, while still being professional? Should we lose neckties, fake nails, and jewelry that might spread infections and be hard to clean?

Or is this discussion a distraction from things that really are a pain in the neck – such as problems with patient safety, quality, waiting times, cost, and staff morale? What do you think? What is your ideal state for healthcare attire? And what it means to your patients or your staff? To your leaders? Would a change in dress code go hand-and-hand with an attempt at culture change or “Lean transformation,” as a visible sign that things are going to be different and we’re shaking up the status quo in healthcare performance?


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

15 Comments on "What’s Up With Neckties in Healthcare?"

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  1. Lindsay Mattino says:

    Hi Mark,

    When I worked in the clinical arena we were not allowed to wear fake nails. It was an infection control issue. In nursing school we had to have our hair back, a practice that ended in school. I think as long as people are clean, groomed and wear clothing that is well maintained and presentable they’re good to go. Of course, I don’t believe wearing jeans, mini skirts or low cut shirts should fly. I obviously won’t be able to focus on what someone is saying if their bare midriff is showing! I see a happy medium here. One’s intelligence should not be judged purely on his or her wardrobe; however, I also don’t want a fake nail in my medicine cup!

    • Mark Graban
      Twitter:
      says:

      Yes, there are other things that potentially cause infection control concerns, including long sleeves.

      I, of course, don’t believe in dressing unprofessionally. Jeans, midriffs, sandals, etc… that’s probably considered unprofessional by most standards. Professional looking doesn’t always mean a tie, in my view. I’ve seen some people who look unprofessional in a tie because their shirt’s top button is open and the tie’s knot is all messed up. Or their shirt is super wrinkly.

      I like how the new GM Mary Barra had previously, when in charge of HR, reduced the corporate dress code policy from something like 40 pages to a simple declaration of “dress appropriately.”

      Women don’t have to wear ties and can certainly be in professional looking suits and apparel that’s not to the “suit and tie” level of formality. I think a parallel to the potential discomfort of a tie for women is panty hose. I’ve talked with my wife about this a lot… panty hose was a part of traditional business formal apparel for women, but can be uncomfortable. Do bare legs really offend anybody in a professional workplace any more?

      Some of this is generational, I’m sure. I’m curious what will happen over time.

      I’m at a hospital this week where the CEO was in a suit and tie, the CFO was in a suit jacket, sweater, shirt, no tie, the the PI leader was “business casual.” All looked professional to me.

  2. I’ve worked in environments that range from uniforms for all staff from factory workers to CEO, to business casual environments, all the way up to suit and tie every day. As mentioned in your post the shirt and tie environment was first encountered when I move from manufacturing to healthcare (which is my current job). I took each one as the culture norm for that work environment and went with it (because we’ve always don’t it that way). It didn’t bother me either way. I certainly agree that it is important that work attire be appropriate for the work environment in regards to employee safety concerns. No ties on factory floors or in direct clinical applications for infection control reason. Personally, I believe dress code had no real effect on my personal productivity, quality, and/or work moral. Can it make you feel better? It depends on the person. I believe the thought process behind it is for the image and brand it portrays to your customers. Now the real question is, “Do your customer really care about work dress?” Is there research out there to tell us either way?

    I imagine in manufacturing some believe that uniforms are important for potential customers that might walk through for site visits or current customers for inspection visit. I can certainly see the perception of walking through a plant and seeing employees in professional uniforms versus employees in jorts (http://en.wikipedia.org/wiki/Jean_shorts ) and a “I’m with Stupid ” T-shirt. Should they care about their appearance? No. Should they care about the product? Yes. Good or bad I feel like this judging occurs commonly and the impression can make a difference.

    In healthcare one reason there may be a continuation of traditional business attire is because the customer is always present. Do certain groups need more formal attire like Chaplains or clinical leaders that sometimes have to deliver tough news? I can see this being respectful for the patient and families in their situation. But then it goes back to my original question, “Do your customer really care about work dress?” I don’t have answer for you. It would to interesting see some research and/or a poll showing either way.

    How about a poll for the group? If you walked into a JW Marriott on their casual Friday and the concierge was wearing cargo shorts and a Hawaiian shirt, would you care?” That’s ultimately up for the customers to decide with the almighty dollar. I certainly don’t think it’s that easy in healthcare.

    I also agree with you that respect and professionalism are behaviors not appearances. But this can go either way. I can wear scrubs and still be very disrespectful. I can and currently do wear a shirt and tie (again cultural norm) and firmly believe I am respectful and people know that I am respectful because of my behavior not my dress. Like you said, appearance has nothing to do with respect.

    So back to one of your original questions, “Does more formal attire matter the least bit for healthcare quality, patient safety, respect in the workplace or other factors?” I think no. “Do your customers really care about work dress?” I think quite possibly yes. In the mean time as Barney Stinson says in the TV show “How I Met Your Mother” I will continue to “Suit Up!”

    • Mark Graban
      Twitter:
      says:

      Thanks for your comment, Isaac.

      “Do your customer really care about work dress?” Is there research out there to tell us either way?

      Yeah, I’d be curious about this too. What I hear is a lot of supposition from leaders and doctors about what they think their customers want. “They want their doctor to wear a shirt and tie, it’s a sign of respect” or “They staff respect me more if I’m wearing a suit and tie” seem more like guesses than fact. What do the customers think? I can’t only speak for myself, when I think I’d be fine with a doctor in a nice polo shirt with a hospital / clinic logo on it. I might be suspicious of a doctor who was dressed in too slick of a suit (is he superficial and too focused on his appearance instead of things that matter to me as a patient?).

      How about a poll for the group? If you walked into a JW Marriott on their casual Friday and the concierge was wearing cargo shorts and a Hawaiian shirt, would you care?” That’s ultimately up for the customers to decide with the almighty dollar. I certainly don’t think it’s that easy in healthcare.

      If the JW Marriott was in Hawaii, that would totally appropriate :-)

      You’re right that it should be up to the customers, but it’s easier for patients to choose a doctor or hospital based on how they dress rather than choosing based on good cost and quality data.

      • “It’s easier for patients to choose a doctor or hospital based on how they dress rather than choosing based on good cost and quality data.”

        This has always be a frustration of mine. I know more about my electrician and plumber through reviews and the BBB then I do my general doctor or surgeon. The only way I know to find a doctor is through recommendation. General, I think recommendation are based on how nice someone is not their quality of care or abilities.

  3. Mark Graban
    Twitter:
    says:

    From Paul DeChant on Twitter, a former hospital CEO:

    HC execs wear ties cuz docs do. Docs were acculturated in med school-conservative-slow to change-not good for infxn control

  4. Mark Graban
    Twitter:
    says:

    Some other thoughts from the interwebs:

    What doctors wear: Do we care too much?

    There are some studies that “suggest” that patients better trust doctors in ties.

    “Respondents overwhelmingly favor physicians in professional attire with a white coat. Wearing professional dress (ie. a white coat with more formal attire) while providing patient care by physicians may favorably influence trust and confidence-building in the medical encounter.”

    From the BBC:

    Would you trust a doctor in a T-shirt?

    Since 2007, UK hospital infection rates have indeed gone down, but according to Dancer – a microbiologist – there is no evidence that this is because of the absence of ties and coats, as hospitals introduced a number of hygiene measures at the same time.

    The BBC article sites a study that showed people four pictures of doctors… after doctors have worn ties and white coats for so long, haven’t patients been conditioned to expect that? Some of these studies might be an exercise in confirmation bias. “Doctors have always worn ties, so therefore somebody in a tie looks like a doctor” might be the thought of those being surveyed?

  5. Peter Liepmann MD FAAFP
    Twitter:
    says:

    Way back in residency, I saw long ties as a potential infection hazard, and decided to wear bow ties instead. I found people reacted strangely to me, wondered why, read ‘Dress for Success’ and found that bow ties have an association with swindlers and other untrustworthy types. So I put the bow ties away and started wearing long ties that I tucked in. Mostly necessary in the East US. Since coming to California, I’ve found people don’t generally wear ties, so its less needed. It all comes down to how people see you. In ‘White Coat, Clenched Fist’ a reporter (white guy, long hair, long beard, jeans. flannel shirt, sockless sandals and mil surp wool greatcoat) describes walking through the ER waiting area at Lincoln Hospital and having people touch his sleeve and ask “Doctor, could you…?”

    • Mark Graban
      Twitter:
      says:

      Why did they think the reporter was a doctor? He didn’t seem dressed like a doctor. If I wore a shirt and tie and a white coat and put a stethoscope around my neck, I might get arrested for impersonating a physician when somebody asked, “Doctor, could you….?”

  6. George Harvey says:

    Ladies and Gentlemen…I present the next Andy Rooney!

    I like the post…very Rooneyesque. As one of those hospitals with a necktie policy, I have to say that I’m used to it and it doesn’t really bother me. Sometimes I even like to wear a tie. That said, I don’t think it should be required and, as long as someone is professionally dressed, I don’t think it matters at all.

    As long as beards aren’t outlawed I’ll be happy.

  7. Mark Graban
    Twitter:
    says:

    Even Dilbert’s workplace has gone business casual.

    And that includes the pointy haired boss.

    But some executives in the strip still wear ties. They must be higher up.

  8. Mark Graban
    Twitter:
    says:

    I did see, this week, a survey about how 57% of CEOs now wear business casual… as opposed to my estimate of 5% of hospital CEOs wearing business casual.

    https://twitter.com/MarkGraban/status/578579009115582464

  9. Gary Boos says:

    In the construction industry,manufacturing, nuclear power, chemical (and others) the most important factor (repeated and emphasized frequently, sometimes daily) is safety.

    Safety dominates all other factors.

    No action or condition that lowers safety is accepted.

    It seems the health care industry believes that “looking professional” of achieving better customer satisfaction, or avoiding disapproval from other doctors or changing dress habits is more important than safety.

    Supposedly “germ theory” is accepted by all. Requiring to data to determine whether or not ties carry pathogens is not justified, or moot. The ties might carry them (and the risk for them to be contaminated arises every work day) and therefore it is not safe to wear them.

    Routinely wearing a garment that might carry pathogens, and, deliberately not cleaning them, in a workplace in which patients “catch” or acquire infections (HAI) is reckless and endangers the patients. Its’s Reckless endangerment. That is criminal. To think otherwise is denial. {opinion: I think this is similar to sexual abuse by the Catholic Church – see Spotlight.}

    I expect that there must have been some District Attorney whose loved one has died from HAI, where the doctors routinely wear ties. Hospitals should expect to be indicted for Reckless Endangerment. To expect otherwise is denial.

    I hope I am not the first to declare this. If I am, I have used my small voice to alert the industry.

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