After her OSCE in July, Eilidh Wilcockson, a third-year medical student at Newcastle University, received some surprising feedback: not about her clinical knowledge or examination technique, but about what she was wearing. [1,2] She had been given a “professionalism yellow card”, which is normally used to report violations of confidentiality, offensive language, or causing patients’ discomfort. As in a football match, cards can lead to disqualification. The specific grievance in this case was about the student’s “short dress with no leg coverings.” The “role player commented immediately after [the] station that [it] looked unprofessional,” the notes on the card allegedly said. The examiner had added, “I agree.”
The dress in question was dark navy with a subtle grey check. Sleeves fully covered the student’s deltoids and axillae. The V-neck’s point reached the second intercostal space. Distally, the dress entirely hid the knees. The student had chosen flat shoes. She wore no jewellery and, as per NHS protocol, was bare below the elbows. Approximately 30cm of calf was also bare between the tibial tuberosity and ankle. It’s uncomfortable to describe a person’s appearance with anatomical accuracy unless that’s your job. It was the examiner’s job to assess the student’s clinical interaction with the patient, not to disparage her clothing choices. If given free rein to make these remarks, examiners can lean into exclusionary ideas of what is appropriate.
The initial response when the student queried the yellow card? She was told it was “the most inappropriate dress they had ever seen in their entire time of examining.” After attempts to respond to the accusation through the University’s formal complaints procedure, Wilcockson’s friend tweeted the story with a photograph of the outfit. MedTwitter erupted.
“Have you attached the wrong photograph?” asked @Drbillgibson in response to the image, “That’s of someone wearing pretty conservative business attire.” @Drlyndarose agreed, thinking that “the picture was an example shown to the student of what they *should* have worn.” “Is this one of those magic dresses that looks different to different people?” quipped @Kumaranism. “It looks navy to me but perhaps it looks see-through to misogynists?”
In the messages of solidarity, sartorial freedom seemed to align with seniority. “I am a consultant,” wrote @Mariekeemonts, “never ever do I wear tights in summer. Never had any complaints.” @Flynnmarina described the outfit as “exactly the sort of thing I advise my trainees to wear for the Part 3 MRCOG exam or to give a paper at a conference.’’
Meanwhile, juniors shared their humiliating experiences. One had been criticised because a patient “could see the change in gradient of colour in her tights when she sat down.” One doctor remembered “comments on my sleeveless shirt for an OSCE once. Was on SSRIs at the time and the combo of sleeves + anxiety made me incredibly hot. As a still-overheated doctor I only wear sleeveless tops and I’ve never had a single comment or complaint.” @ARODMDPHD despaired that the takeaway from her negative interactions seemed to be “women are distracting, please wear [a] paper bag.”
Standards of professional dress for women have varied wildly throughout history, while standards never stay still long enough for us to catch up. The requirements for women doctors are more erratic than other professions. In the late 1960s, female doctors would be sent home to change if they arrived on the wards having “covered [their] legs with trousers.” Commenting on the photograph of Wilcockson, @EMTdocAndy, pointed out that “military dress uniform skirts are almost exactly that length and have been for many many years. I’d suggest if it was long enough for the bastion of conservatism that was RMA Sandhurst in 1990 it’s long enough for an OSCE!” The appropriateness of an individual’s appearance is also context specific: if you’re the parent of a baby, vomit on the shoulder of your shirt is surely a forgivable imperfection; if you’re hungover, it’s almost certainly not; if you’ve just come from assisting a nauseated patient in the corridor, the stain is a manifestation of your professional duty.
People who are not cis, slim, straight, white, and male stand a greater chance of being labelled as “inappropriate.” Men just seem to get away with more. For example, several shared that they had done their OSCEs in shorts without formal criticism. Women’s “flaws,” including their busts, bottoms, sweat, hips, wet hair, dyed hair, big hair, VPLs, bra straps, ankles, shoulders, arms, nails, earrings, skin or make-up can, and will, be called out. The policing of certain bodies smacks of high school uniform requirements to “prevent” girls from distracting the boys. But it is our professional duty to be comfortable with bodies of all shapes, sizes, sexes, and altered by choice, pregnancy, lifestyle, disease, or surgery.
Many have asked, where is the harm in setting standards for women’s dress if they still pass the exam, ace the presentation, or secure the promotion? These incidents cause immediate as well as lasting distress. The daily work of trying to conform to outdated, discriminatory, and unpredictable “standards” is tiring. To source clothing which is not too loose or tight, not too bold and flamboyant, with a high enough neckline and a low enough hemline, sufficiently feminine (the list goes on) takes time, money, and mental energy. After preparing for and delivering another gruelling audition for this profession, a comment about your appearance is a jarring humiliation. Each time the effort is judged to be insufficient, and dress codes are enforced by the whim of a person in power, access to the profession narrows. That’s the harm: whom we demean, and whom we leave out.
These conflicts are not unique to the UK. In North American residency interviews, conversation between hopefuls often turns to whether wearing trousers instead of a skirt, or flat shoes rather than heels, is worth the “risk.” These risks seem even greater in male dominated fields. Obligatory heels for surgical interviews should be a flattering height, but not too “sexy.” For a profession that prides itself on practical and often physical work, these requirements feel particularly out of place. The consequence of missing the mark can mean a person’s future in a specialty is jeopardised. US medical schools retain incidents of unprofessionalism in performance records which are submitted with training programme applications. Should a professionalism violation be upheld, details will be distilled over time, leaving a permanent mark on a student’s record which then cannot be compassionately reinterpreted.
The NHS’s current unwritten dress code clearly isn’t working. The details need to be guessed by doctors while sizing up the prejudices of their seniors and erasing their own social, cultural, religious, and economic backgrounds. Of course, there are inappropriate ways to be dressed as a clinician. But no single outfit will satisfy the opinions of every one of our patients.
Might a uniform simplify things? Perhaps, but it would have to be inclusive, debated, published, and reviewed. If “leg coverings” were enforced, there would at least be an opportunity for coordinated outcry. During the pandemic, the routine wearing of scrubs simplified aspects of daily decision-making. If they continue to be acceptable for all, staff deserve scrubs that comfortably fit and protect a variety of bodies. Currently, these glorified pyjamas masquerade as being “unisex,” but are designed for slim men.
The question of dress is connected to many other issues in a culture of professional sexism. A BMA report published last month found that nine out of 10 female doctors in the UK have experienced sexism at work. The “failure to address structures and policies that favour a workforce of men, allowing sexist attitudes and gender bias to remain prevalent has led to unequal opportunities for women…[and is] causing problems in their day-to-day working lives,” the authors conclude. Why is this only coming to light now? Why haven’t women said anything? They have, daily, on and offline. But complaint processes are time consuming, emotionally fraught, and rarely lead to satisfactory outcomes. Speaking up can also prompt further questions about professionalism. In this case, Newcastle University responded to concerns about the issuing of a yellow card to Wilcockson via Twitter, apologising “for any offence or distress caused by this incident.”
“All comments made by patients in exams are passed on to students as feedback,” the university said. Really? Would the university have passed on racist, homophobic, or other discriminatory comments to a student? The minimum professional obligation of a clinician, or examiner, is to filter out tangential personal opinion, even if they happen to agree with it.
Criticisms of a colleague’s appearance are unacceptable—that is unless the critic is prepared to forensically detail the infringement in writing and defend it formally. If the transgression is not egregious or part of a long term pattern, it is surely right not to comment.
Part of being a professional lies in protecting colleagues from these kinds of accusations, and in contributing to a working environment that respects the humanity and dignity of every one. Professionalism is about values, not hemlines. Changing the clothes does not fix the problem, because the problem was never just about clothes.
Kate Womersley is a GPST1 in NHS Lothian, and research associate at The George Institute for Global Health.
Helen Hare is ACCS (Internal Medicine) Year 3 in NHS Lothian.
Stephanie BH Kelly is an Intensive Care Clinical Fellow in NHS Lothian.
Eilidh Wilcockson is a third-year medical student at Newcastle University.
Competing interests: none declared.
- Objective structured clinical examination
- The medical student, EW, is a co-author of this commentary, to ensure her experience is correctly represented and her views heard.