You can keep your pants on


Hospital gowns have been the butt of jokes for decades, yet almost all inpatients still have their nether regions effectively unclothed during their hospital stays.

Todd C. Lee, MD, MPH, and his colleagues want to change that. Hospital attire “that leaves the backside and genital areas unnecessarily exposed has an important effect on dignity,” they wrote in a research letter, published by JAMA Internal Medicine on Sept. 22, 2014, that recommended allowing inpatients to wear lower-body attire when feasible.

A small survey at the researchers' Toronto and Montreal hospitals suggested that patients support the concept: Thirteen of the 17 patients who could have been wearing pants but weren't said they would have liked to. The survey of physicians, however, was more divisive: Toronto physicians considered only a third of their patients eligible to wear pants, compared to two-thirds of physicians in the Montreal hospitals.

ACP Hospitalist recently spoke with Dr. Lee, who is an assistant professor of medicine at McGill University in Montreal.

Q: What led you to study inpatient attire?

A: When I was training, I specifically remember a patient who was a professional. He asked for permission to go out and attend a very important meeting in the afternoon and so he changed out of his gown and he put on his suit. I remember seeing him later that night, walking down the hallway with no pants on and an open-backed gown, struggling to hold it closed behind him. I thought to myself that it really just didn't make sense for him to be wearing that gown.

Later on, I was at a dinner party and was hearing about someone's mother who was admitted to a South Korean hospital, and she said that she was wearing easy-to-put-on, large-buttoned hospital pajamas that were provided. She had a photo. Sure enough, she was in a very dignified-looking patient outfit and I wondered why it was that most patients I had seen weren't provided the same.

Then I read Allen Detsky's editorial [“Reducing the Trauma of Hospitalization” in the June 4, 2014, Journal of the American Medical Association in which Dr. Detsky and Harlan M. Krumholz, MD, wrote that “patients should be encouraged to wear personal items of clothing”]. That crystallized, with those other things, my interest in understanding what our patients were wearing and whether they could indeed be wearing more.

Q: What did you think of your study's findings?

A: I had a sense that I was probably going to find that the majority of patients were not wearing more than the hospital gown. I didn't think it was going to be as low as 10% or 11%, which is what we found. We were surprised by the substantial variability between attending physicians in what proportion of their patients they said would be eligible to wear pants if the patient asked.

When I specifically interviewed patients who were not wearing lower-body garments and were eligible, I wasn't surprised that the majority of them wanted to. I was surprised a little bit by some of the responses I got [from other patients]. Two major themes: One of them is “I'm too sick to go through putting on more substantial clothing.” The other one, which was much more pervasive, is they say, “I'm a patient. This is what patients wear.” They didn't seem to recognize that they could be wearing more, and some of them didn't want to wear more.

Q: If patients do want to wear more, should the impetus be on them to request that?

A: I don't think it should necessarily be on patients. Patients should have the right or be encouraged if they want to wear more substantial attire. Look at concepts like the Acute Care of the Elderly units—I think that encouraging [more substantial] patient attire in that context is associated with patient empowerment, maintenance of activities of daily living, and, potentially, in addition to the benefit of dignity, could be associated with the benefit of reduced length of stay. Maybe institutions should be a little bit more proactive in encouraging more complete forms of dress when appropriate. It might have a number of unexpected benefits.

Q: How do physicians react to that proposal?

A: The article was released in September, and I've had a lot of surprising interactions with colleagues [since]. There are some people who say, “Of course we should be doing this, and I never really thought about it, and I can see how it's important.” And then there's another subgroup of physicians who are concerned that potentially important clinical findings could be missed, or that in more significantly ill patients, there could be barriers to managing them during critical illness if they were wearing more substantial attire.

Q: Is this an issue of hospital policy?

A: I think it's definitely an unwritten curriculum, an unwritten policy. I'm not aware of any official, written hospital policy that says “The patient shall wear a gown.” There are certainly institutions that I'm aware of, even within Canada, where the culture is very different and patients are encouraged to wear more complete attire or it's provided for them. It's more of a local, regional, institutional culture issue.

Q: Is it preferable for patients to bring their own attire or for hospitals to provide lower-body garments?

A: There are advantages and disadvantages to both. The advantage of home attire is that one, it doesn't necessarily cost the hospital any money to provide, and two, it makes a patient appear more like a person than a patient, which can be important in terms of people's interactions. The disadvantage with home attire is ensuring that it's appropriately laundered and clean and perhaps increased caregiver burden in laundering or providing this clothing. [With] hospital-provided attire, there are certainly increased acquisition and laundering costs. The hospital gown is incredibly inexpensive and easy to launder and “one size fits all.”

Q: What advice would you give to hospitalists on this issue?

A: We should be mindful of the effect that patient attire can have on patient perceptions of dignity and potentially on maintenance of the activities of daily living and length of stay. I think that we should try and be open-minded to the concept that patients may prefer to have a more dignified set of attire and offer that when it's appropriate for the patient to do so. I'm certainly encouraging all of my patients to bring in clothes if they'd like to do so.

Q: What advice do you give them about bringing their own clothes?

A: I'll make suggestions for loose-fitting clothing that's easy to launder and that they're going to feel comfortable walking around the hospital in. Many times that could be pajamas. Or that could be jogging pants or sweatpants, something that's relatively easy to get on and get off in the case that we need to do an examination of that area or perform a procedure. I find most patients are really receptive, and within the next couple of days, I'll see them wearing clothes in the hospital and walking around.

Q: Are you doing any further work on this issue?

A: We're trying to find a corporate partner to design some sort of hospital functional fashion that we could test, as we're looking to open our own Acute Care of the Elderly unit. I think there's a lot of great fabrics and a lot of talented people in fashion, and I think there's a little bit of interest in this now, so we're looking at whether we could come up with something locally for people to wear that would be satisfactory.