Psychiatrists’ Attitude to the Psychiatrist’s Style of Dressing and Addressing: A Cross -Sectional Study


 Background The relationship between physician and patient is important topic in medical practice. How a physician dresses and addresses the patients are key factors that contribute to developing a rapport. This study aimed to investigate the psychiatrist's perspectives in order to facilitate an effective communication with patients.Methods This descriptive-analytic study was done on psychiatrists and psychiatric residents through a non-selective and non-randomized sampling method. Data were collected based on a questionnaire. Variables were such as age, sex, duration of practice as a psychiatrist, priority for male psychiatrist dress preference, priority for female psychiatrist dress preferences, priority for choosing a doctor from a gender perspective, priority for being addressed by patients, using the word of the gentleman or lady to address the patients, and the type of verbs and pronouns used by the psychiatrist and the patient during the interview in terms of the total number of verbs and pronouns. Subsequently, eight photographs of male and female physician’s coverage according to the in Iranian culture were shown to the participants and they were asked to choose one.Results A total of 77 psychiatrists participated in this study, of which 45 (58.4%) were male and 32 (41.6%) were female. In case of male psychiatrist’s coverage, 56 (72.7%) participants preferred suits; whereas in case of female psychiatrist’s coverages, 25 (32.5%) participants chose colored mantos and scarves, 22 (28.6%) selected black manteos and head dresses. Sixty three (81.8%) patients believed that the gender of the physician was not important in determining the treating physician. According to the type of addressing the psychiatrist by patients, 71 (92.2%) participants preferred to call the doctor's name followed by surname and 60 (77.9%) psychiatrists wanted patients to use the word "Mr. or Ms.” prior their names. Sixty three (81.8%) psychiatrists stated that it was better to use plural pronouns and verbs in interviewing patients, and 67 (87%) preferred their patients to use plural verbs to address them.Conclusions Psychiatrists’ appearance and the accuracy of the patient-referring type, based on what the physicians believe, along with the characteristics of the patients’ perspectives, help improving physician-patient relationship.

such as Iranians prefer non-occupational coverage without a white coat for the psychiatrist to wear [10].
As far as the way of addressing is concerned, studies reports patients mostly prefer to be referred by first name while addressing the psychiatrist, "doctor followed by the last name" [11] Since different nations do not show the same attitude toward this topic [12][13][14], we aimed to investigate the effect of cultural factors on the attitude of psychiatrists toward the type of psychiatrists' coverage and the way in which patients are referred by them locally. According to the Mental Health Database Research Center at Iran National Research Center for Nursing and Midwifery as well as the Iranian Information and Evidence Center there has been only one similar study in Iran so far. This will give us the opportunity to compare the attitudes existing between patients and psychiatrists.

Methods
The present research is a descriptive-analytic study with a non-selective and non randomized sampling method. It was carried out in December 2018 at the annual congress of the Iranian Psychiatric Association. The study conducted on psychiatrists and residents who participated in the congress. A number of 77 individuals (45 male and 32 female) from both sex included our sample size. The nature of the study was explained to them by the letter of information. The Questionnaire was developed by the authors by taking the cultural characteristics of Iran into the account and by reviewing the literature on this topic. Questions were approved both by the authors and the ethics committee in terms of practicality and intelligibility. We obtained information through a two-part questionnaire. During the first part, we collected information on variable such as age, sex, duration of practice as a psychiatrist, the priority for male psychiatrist dress preference, female psychiatrist dress preferences, priority for choosing a doctor from a gender perspective, priority for being addressed by patients, using the word of the gentleman or lady to address the patients, and the type of verbs and pronouns used by the psychiatrist and the patient during the interview in terms of the total number of verbs and pronouns. The second part of the questionnaire included separate color photographs of both male and female doctors with different costumes accepted by the Islamic Iranian culture. Each photograph sized 9 by 12 cm. The male psychiatric clothes included t-shirts and trousers (1), medical white coats (2), suits (3), as well as shirts and trousers (4). Female psychiatrist's cloths included (1) colored mantos and scarves (1), black headdresses and white medical coats (2), black veils (3), and black head dresses and mantos (4). The same face was used for all photographs. The questionnaire was completed by psychiatrists.

ETHICAL CONSIDERATIONS
Ethical approval was obtained from the Ethics Committee at Shahid Beheshti University of Medical Science (SUBMS), Tehran, Iran. The study was also recorded in the research and technology department of SUBMS under the code of IR.SBMU.RETECH.REC.1398.138. Permissions were obtained from the hospital and psychiatry unit authorities. The researchers informed participants about the purpose and the course of the study. The individuals were free to withdraw from participation in the study at any time if they wished to do so. Participants were also assured regarding confidentiality of the data, and absence of any constraint to participate. A written informed consent form was obtained from participants prior to enrollment in the study.

STATISTICAL ANALYSIS
Data were analyzed using descriptive statistics techniques by means of SPSS software (V.13).
Descriptive statistics were used to summarize the value of the variables of interest in percentages.
Nominal Variables such as type of coverage preference were presented as frequency and percentage, respectively. They were and compared using the chi-square test. Continuous variables were presented as mean and standard deviation, correspondingly. The t-test was used to determine the relationship between female and female psychiatrist's age. Chi-square test was used to determine the relationship of coverage preference and age, sex, and number of years of work experience. Likewise, Chi-square test was used to determine the priority of choosing a physician as well as the way the psychiatrist addresses the patient and vise versa.
In terms of the way the psychiatrist is addressed by patients, 71 (92.2%) chose the doctor word followed by physician' surnames, one (3.1%) preferred the doctor's word followed by first name, and three (3.9%) individuals opt to call the physician only by last name; while for these viewpoint there were significant differences (X2 = 127, df = 2, P < 0.0001). Sixty (77.9%) physicians believed that it would be better to use the word "male or female" prior to their names, whereas 17 (22.1%) physicians disagreed with this opinion.

Discussion
This study showed that most psychiatrists prefer suits for male psychiatrists to wear while they prefer colored mantos and scarves or black mantos and headdresses for female psychiatrists. According to them, the most important factor in choosing a physician was about his skills, not his gender. Most of the psychiatrists addressed their patients using the word of gentleman or lady and they would like to be referred to as doctor and a surname. Likewise, they preferred patients to address them by a plural verbs and a pronoun, while the patients also prefer to be addressed using a plural verb and a pronoun.
In Gledhill's study, most psychiatrists also selected suits and ties as suitable coverage for psychiatrists, which are close to this study, regardless of cultural differences [15]. However, both studies conducted by Lavelle and Mast showed most medical doctors wanted to have appropriate coverages, although one was conducted among psychiatrists and the other one studied on physicians regardless of their specialties [16,17]. In the present study, like the study of Gledhill, most psychiatrists tended to be addressed by title and surname, and similar to the study of D'Agostino, most physicians called the patients as gentleman, lady or patient's surname, although the second research was conducted on physicians other than psychiatrists [15,18].
There is a fundamental difference between the results of the present study and Semnani's research on this topic. In contrast to this study, Semnani reports most patients preferred white coats for male and female psychiatrists. They mostly wanted to be called by their first name, but they did not care about the gender of their physicians [19]. The distinction between what a therapist recommends to the patient and patient's own preferences suggests that in the therapeutic programs the patients' wishes should be considered as the main goal of the treatment as this is very important in establishing a therapeutic relationship [6,20]. For example, Pope et al. have shown that what causes patients with bipolar disorder to discontinue lithium is completely different from the viewpoint of the therapist and the patient [21].
According to previous study the patients preferred to be addressed by psychiatrist by first name [22].
The patient's age significantly influenced their preferences. Patients who preferred to be called by their first names were significantly younger than those who wanted to be addressed by their surnames. The only other variable that influenced this preference was patient's ethnicity. Gender or socioeconomic classes did not have any impact on their choice [23]. Patients' preference for psychiatrist attire largely differed based on the geographic locations. White coat, casual clothing, and official dressing were preferred depended on where the patient lived, however, admitted patient were significantly more willing to see the psychiatrists while they wear a name badge. patients' preference for the most part varies based on cultural and socio-economical classes [24].
Although our study was of a descriptive research, we got a chance to explore the psychiatrists' opinion and what is happening in the real life. Our study along with the previous ones on this topic may provide leads in identifying what changes are required in clinical encounters. Our methodology of data collection was well designed as well. The questionnaire we prepared for the purpose of the study was able to provide information from both patients and psychiatrists. Since psychiatrists from different province of Iran who participated in a congress included our sample, data collection might have spread over a relatively large geographic area. Nonetheless, our study had a limitation as well.
We were not able to carry out more accurate statistical evaluations due to insufficient sample size.
Therefore, further studies on this topic are suggested using a larger sample size associated with a control group and an inferential statistical approach.

Conclusion
According to the present study, psychiatrists mostly prefer to visit patients with an ordinary coverage other than a white medical coat. They are also willing to call patients to their last names while they want patients to deal with them as a stranger. It seems psychiatrists do not feel comfortable if patients want to be so close to them. Although, in some cultures, being a second person to be addressed or pronounced is a way to create a better rapport, this does not seem to be the case in Iran. Therefore, the psychiatrist's method of treatment differs according to the customary and cultural conditions where it is practiced.

Declarations
Ethics approval and consent to participate: Ethical approval was obtained from the Ethics