Tie One On for Patients

“Many of our patients are already struggling to find the line between reality and fantasy. Don’t make it more difficult for them.” My appropriately attired Residency Program Director said this on our first day while projecting the image of a woman from the waist down wearing a skirt that worked very hard-but ultimately failed-to make it to the middle of her thigh.

For the men in my program, the length of skirt a woman wears to the hospital is generally a non-issue, but the question of whether to wear a tie is an ongoing debate. As the supervisor for the medical students who rotate on the psychiatry clerkship at our hospital, I require that male students wear ties and believe that all men training in psychiatry should wear ties when performing their clinical responsibilities.

In my experience, these are the common complaints by residents who want to come to work tie-free and some simple rebuttals if you, as I do, wish to see future male psychiatrists adorning neckwear:

•Wearing a tie is uncomfortable. This is one of the easiest arguments to rebut. When a patient comes to a hospital, her first thought should not be “Thank G-d, I have to come to the hospital where my doctor appears really comfortable!”

The patient’s first impression before any verbal communication should be, “My doctor looks like a professional and will likely guide my care professionally.” The tie is by far the most uncomfortable article of clothing. And far from being a reason to discard it, it is good reason to allow ourselves to be embraced by it. By sacrificing our own personal comfort, we inspire confidence from the people who look to us for help and relief by letting them know their comfort is most important.

•Wearing a tie is unsafe for patients. On the basis of studies that show dangerous bacteria can be cultured from the neckties of some physicians, there could be some merit to this argument in the general medical hospital, although the author of the leading study on this topic has stated, “There is no direct evidence to implicate neckties in the transmission of infection to patients.”¹

Regardless, with the exception of situations in which the psychiatrist is required to do a physical exam, you are not practicing good psychiatry if your tie is regularly rubbing up against multiple patients in the course of a day. On the occasion that a psychiatrist is required to do a physical exam, he can simply remove the tie for the exam or tuck it into his shirt.

•Wearing a tie is unsafe for psychiatrists. The reasoning behind this statement is that a patient may become violent, grab the physician’s tie, and use it as a choking device. Flaws in this reasoning begin with its offensiveness to the overwhelming majority of psychiatric patients who are far more likely to be the victim of an assault rather than its perpetrator. Further, if this logic is applied by the psychiatrist working on an inpatient unit, he must consider whether he is creating an environment that is safe in general.

Although choosing to forego wearing a necktie may prevent harm to his person, what about the 20 or so other patients who are spending 24 hours a day in a locked unit with this potential menace? This argument also falsely assumes that the person who wishes to do the physician harm will just decide to move on if his chosen target is not wearing a tie. In the unfortunate and (I hope) rare occurrence that a patient requires seclusion or restraints because of agitation, removing one’s tie is certainly appropriate while managing and assessing this patient’s acute agitation.

•Wearing a tie is no longer required for successful men in contemporary society. This argument is often accompanied by asking me to consider images of billionaire innovators such as Steve Jobs or Marc Cuban. I have a difficult time refuting this argument (see exemptions below).

I do accept there are certain few psychiatric trainees who should be exempt from wearing neckwear.

•Following the Steve Jobs–Marc Cuban argument, I have developed the “billionaire-genius exemption.” If you are a billionaire and a genius, I will defer to your judgment on the tie/no tie question and likely seek investment advice from you. Thus far, I have not required any of my billionaire genius medical students who prefer to go tieless to wear one.
•The innately dangerous clinical setting: While training in forensics, one’s work may frequently bring one into contact with known violent individuals, during which the psychiatrist is often involved in a role that may be perceived as adversarial.
•The carotid massage excuse: When I was interviewing for medical school, one of my interviewers began by apologizing for not wearing a tie and explained that he has heart trouble. After several syncopal episodes, his cardiologist determined that the cause was his closed-neck shirts massaging his carotid arteries, thereby lowering his blood pressure. If wearing a tie is likely to result in syncope by a well-described and documented mechanism, you are certainly encouraged to forego wearing one.

Even as residents, we are all privileged to tremendous responsibility in the care of our patients. Let us all work together to make sure they see us as adequately dressed for this role.

Reference1. Bhattacharya S. Doctors’ ties harbour disease-causing germs. New Scientist. May 24, 2004. http://www.newscientist.com/article/dn5029-doctors-ties-harbour-diseasecausing-germs.html. Accessed February 13, 2012.