Does the Appearance and Mannerism of Doctors Affect Doctor-Patient Relationship? A Cross-Sectional Study among General Population in Malaysia

Delisha Kaur Boparai1, Keeran Ramesh1, Ama Thathsarani Rajapura1, Dushan Uvindu Gunawardana1, Thin Mon Kyaw2, Htoo Htoo Kyaw Soe2, Soe Moe2, Nivedita Nadarajah3, Mila Nu Nu Htay2*

1Faculty of Medicine, Manipal University College Malaysia, Melaka, Malaysia

2Department of Community Medicine, Faculty of Medicine, Manipal University College Malaysia, Melaka, Malaysia

3Department of Medicine, Faculty of Medicine, Manipal University College Malaysia, Melaka, Malaysia

*Corresponding author: drmlnnh@gmail.com

                        Abstract

Background: A strong doctor–patient relationship is crucial for effective diagnosis and treatment. This study aimed to determine the community’s perception toward doctors’ physical appearance, mannerisms, and association with the doctor-patient relationship in Malaysia. Methods: This cross-sectional study was conducted among the general adult population in Malaysia. Data was collected via an online survey and analyzed using SPSS version 27. Results: A total of 389 respondents participated in this study. Over half (55.53%) considered professional attire with a white coat is important, and 90.75% preferred doctors to wear name tags. The respondents paid more attention to mannerisms if they were younger age group (18-30 years) rather than the older age group (50 years and above) (Adjusted OR = 4.64, 95%CI: 1.90, 11.36). While the respondents with higher education levels (Postgraduate) were more attentive to mannerisms compared to respondents with SPM – Secondary Education level (Adjusted OR = 6.77, 95%CI: 1.26, 36.53). Conclusion: The respondents demonstrated increased trust, confidence, and approachability and were more willing to share personal information with doctors dressed in formal attire with a white coat along with name tags. Most respondents felt that both the physical appearance and mannerisms of doctors played a significant role to form a good doctor-patient relationship. Mannerism was considered more important for the doctor-patient relationship among younger aged and higher educated people. 

Keywords: Attire, Physical Appearance, Mannerism, Doctor-patient relationship, Malaysia

Introduction

The doctor-patient relationship is the cornerstone of all patients’ health and well-being (Mun et al., 2019). It can be defined as a concordant relationship in which the patient knowingly seeks the physician’s aid, and the physician knowingly accepts the person as a patient (Puiu, 2022). Establishing a strong and meaningful doctor–patient relationship is essential to obtain personal information, the proper diagnosis, and creating a practical treatment plan (Naughton, 2017). This relationship is dependent upon many factors including the physician’s persona and eccentricity. Symbolic interaction theory correlated the white coat adorned by doctors since the 19th century with the competent authoritative figure they expect in them to ably assist them, a professional who will treat patients with the same respect that they award their own person (Sotgiu et al., 2012).

The first impression a doctor gives in the initial consultation with a patient is crucial in the formation of a doctor-patient relationship. One of the many factors that help in developing a good first impression is the physical attire of the physician (Aitken et al., 2014). Majority of previous studies have proven that a physician’s attire, such as clothing and cleanliness, plays an important role in the patient’s perception of the doctor, mainly regarding the professionalism, capability, and trustworthiness of the doctor (Mun et al., 2019; Naughton, 2017). Among Italian patients, a properly dressed doctor with a name tag gives an impression of sincere interest in their patients while an untidy doctor conveys that the doctor seems to be disinterested (Sotgiu et al., 2012). However, participants did not have much preference towards the physical attire of the doctor in the UK (Aitken et al., 2014).

In addition to physical attire, body art might also have an influence on the perspective of the patients. A tattoo is a permanent image, pattern, or word on the skin which is created with the aid of needles to add multi-colours under the skin that could fade over time (Puiu, 2022; Hauri and Hohl, 2015; Bäumler, 2020). From the perspective of the patients in the USA, the confidence of the doctors could be lowered if the practitioners had tattoos (Johnson, Doi and Yamamoto, 2016). In hospital settings in the USA, patients considered healthcare providers with prominent tattoos as less professional, efficient, or approachable than non-tattooed healthcare providers (Westerfield et al., 2012). Moreover, some patients felt uneasy when being treated by a tattooed dentist (Laskin, Sabti and Carrico, 2021).

Body piercings are body modifications that involve puncturing and creating a hole through which a piece of jewellery can be inserted and commonly done at the ear, mouth, nose, and eyebrows (Preslar and Borger, 2022). After a long history of negative stigmatization, the practice of body piercing has become a mode of self-expression and a tool for enhancing one's appearance in the modern world (Koch et al., 2004). A previous study conducted among medical school faculty revealed that approximately half of the respondents (48%) considered it was inappropriate for a physician to have a nose stud (Newman et al., 2005). Johnson et al. reported that a visible piercing on a medical care provider directly affects patients’ perception of and trust in the provider’s capabilities (Kyle and Mahler, 1996). Although many previous studies have been successful to throw light on the attitude of the public towards piercings, the tension between the right of a doctor to have a body piercing and the effect it might have on the doctor-patient relationship has been scarcely discussed (Kyle and Mahler, 1996; Newman et al., 2005).

Hair colour and hairstyle are two potentially important yet modifiable cues regarding the appearance of a physician (Kyle and Mahler, 1996). Hair style and hair colour were shown to have an influence on people’s perception regarding their professionalism (Opie and Phillips, 2015). Among Italians, they preferred doctors wearing formal dresses with their hair cut short, particularly for male doctors (Sotgiu et al., 2012). Although studies have been conducted on how hair colour affects professionalism, not much research was conducted to find the way it will affect the doctor-patient relationship.

Compassion indicates the ability to sympathize & empathize whilst treating the patient rather than the disease. The time and attention a doctor allocate to interact with the patient should be fair and not hurried nor dawdling and is indicative of the virtue of patience (Chipidza, Wallwork and Stern, 2015). A patient entrusts a doctor with their health, and to do so they need to assess the expertise of the doctor which they correlate not only to his/her qualification and station but also to the level of confidence they exhibit in clinical practice. Communication and vocalization between the two parties are crucial, the patient would assess and be assured by the doctors’ ability to express medical terms in layman's language and the clarity and appropriateness of verbal and non-verbal communication (Johnson, Doi and Yamamoto, 2016). A plethora of studies has been done throughout the globe in this area of research, most of which conclude that regardless of cultural barriers, a healthcare provider’s physical appearance is important, though not as important as a mannerism cultivating virtues of compassion, patience, and confidence amongst many others (Aitken et al., 2014; Johnson, Doi and Yamamoto, 2016).  Although few studies had conducted regarding the perspective of patients on the symbolic association of the white coat with a doctor (Johnson, Doi and Yamamoto, 2016) and the attire of a dentist (Ramainor et al., 2021), none of these studies have focused on the effect of physical appearance and mannerisms on the doctor-patient relationship. Thus, it is arising need to emphasize the importance of physician persona and mannerisms in the doctor-patient relationship for effective delivery of healthcare. This study aimed to determine the community’s perception and attitudes toward doctors’ physical appearance, mannerisms, and its association with the doctor-patients relationship in Malaysia.

Methods

Study design and setting

This cross-sectional study was conducted among the general adult population in Malaysia in 2023.

Sample size and sampling

The expected frequency of confidence and trust in formal attire and white coat (62.5%) (Zahrina et al., 2018), 5% margin of error, and 95% confidence level yields the estimated sample of 360 for this study. A convenience sampling method was employed to recruit respondents.

Data collection

Data was collected from the adult general population in Malaysia via an online self-administered questionnaire. Section one of the questionnaire included socio-demographic data. Section two of the questionnaire was regarding the attire of a doctor, where the pictures of a doctor dressed in a white coat, business attire, scrubs, and casual were demonstrated by the model while maintaining the environment as constant (Appendix). The respondent’s perception of the effect of the attire of the doctor was collected by using a five-point Likert scale (strongly agree/agree/neutral/disagree/strongly disagree).

The third section was regarding whether tattoos affect the doctor-patient relationship and how the size, location, or design of the tattoos affect the perception of the respondent. Section four was regarding whether a doctor having piercings or coloured hair affects the doctor-patient relationship by asking questions regarding the appropriateness of tattoos in different locations and the vividity of hair colour. Section five was regarding how the mannerism of the doctor influences the doctor-patient relationship in which ten conditional statements were included. The responses were recorded with a five-point Likert scale. The questionnaires were content validated by six experts and translated into Malay language.

The content validity index of the items 0.8 and above were included in the final questionnaire. The reliability analysis of the respondents’ perception on the appropriate mannerism of a doctor reported to have Cronbach’s alpha of 0.818. This suggested that the items used to measure this perception have good reliability and internal consistency.

Data analysis

Data analysis included frequency counts and descriptive statistics such as mean, median, and standard deviation. The association between doctors’ physical appearance and mannerisms with the doctor–patient relationship was examined using logistic regression analysis. Odds ratios (ORs) were calculated, with the level of significance set at p < 0.05 and a 95% confidence interval (CI). All analyses were conducted using IBM SPSS version 27.

Ethical consideration

Ethical approval to conduct this study was granted form Research Ethics Committee, Manipal University College Malaysia (MUCM), Malaysia (Reference No: MUCM/ Research and Ethics Committee – 002/2023).

Results

A total of 389 respondents participated in this study. Table 1 reports the demographic characteristics of the respondents. The majority of the study sample (61.6%) represented the age group of 18-30 years, followed by the respondents older than 50 years group representing 15.72%. Approximately two-thirds are females (62.72%). 57% were educated up to a degree level. Urban residents consisted of 74% of the study sample (Table 1).

Table 1: Sociodemographic characteristics of respondents

Note: Postgraduate* including master’s and PhD.

Table 2 reports the respondents’ perception of doctors’ physical appearance and mannerisms in the clinical setting. More than half of the respondents (55.53%) perceived that it is important for a doctor to be dressed in formal attire with a white coat, while the majority (90.75%) preferred a doctor to wear a name tag. In terms of general physical appearance, 54.50% agreed that ear piercing was appropriate, 87.66% for short nails and 72.80% revealed that hair colour could make a difference in their perception (Table 2).

Table 2: Respondents’ perception on doctors’ physical appearance and mannerism in clinical setting

Table 3 presents the respondents’ perception on the effect of appearance to build up trust, confidence, and doctor-patient communication. More than half of the respondents (53.5% to 71.2%) revealed that the doctors wearing their preferred attire were more likely to be trusted, confident and built-up good communication. While 57.1% to 65% considered that doctors having tattoos was not a matter for them. Similarly, 48.8% to 56% considered that it did not matter if the doctor had their preferred hairstyles, nails, and piercings to build up trust, confidence, and doctor-patient communication (Table 3).

Table 3: Respondents’ trust and doctors’ appearance in clinical setting

Table 4 presents the respondents’ perception of the appropriate mannerism of a doctor. The majority of the respondents (78.90% to 98.50%) agreed and strongly agreed that they appreciate and prefer the doctors to show their sympathy, understand their financial status, treating with respect and professionalism (Table 4).

The association between demographic characteristics and respondents’ perception of the important factor for the doctor-patient relationship. The respondents’ perception of the importance of both professional attire and mannerism was applied as a reference in this analysis.  It was more likely that respondents paid more attention to mannerisms if they were younger age group (18 – 30 years) rather than the older age group (50 years and above) (Adjusted OR = 4.64, 95% CI: 1.90, 11.36). While the respondents with higher education levels (Postgraduate) were more attentive to mannerisms compared to respondents with SPM level (Adjusted OR = 6.77, 95%CI: 1.26, 36.53) (Table 5). The model Goodness-of-Fit, Pearson chi-square (P= 0.99) and therefore model fit the data well.

Table 4: Respondents’ perception on the appropriate mannerism of a doctor

Discussion

The physical appearance of a doctor at first impression is crucial in the formation of a doctor-patient relationship. This cross-sectional study was conducted to determine whether the appearance and mannerisms of doctors affect the doctor-patient relationship among the general population of Malaysia.

Over half of the respondents preferred doctors in formal attire with a white coat, followed by casual wear, scrubs, and business attire. This aligns with previous Malaysian studies, where the white coat was deemed most appropriate for dentists (Ramainor et al., 2021). Furthermore, it was preferred in government hospitals and a higher expectation among male primary care doctors (Zahrina et al., 2018). Similar preference was reported in Saudi Arabia that the patients did not prefer doctors wearing modern clothes (Zahrina et al., 2018). All studies conducted across this area of research derived similar results denoting that people were more lenient towards the attire of a doctor donned with a white coat underneath professional or formal attire. Therefore, medical doctors should be attentive to their attire to meet the patients’ expectations and to build a good doctor-patient relationship.

Most respondents preferred doctors to wear a name tag, consistent with a randomized trial where 96% valued name tag use (Schmid, Gerber and Farshad, 2015). Short nails and conservative hair color were also seen as important, aligning with findings from Brazil, where extravagant hair, long hair, and earrings, especially in male doctors, which caused discomfort to patients (Yonekura et al., 2013).  Nail hygiene among healthcare providers is important to prevent infection (Yonekura et al., 2013) and long nails were considered as a negative quality of healthcare providers in Lebanon (Ayoub, Fares and Fares, 2015). Controversial appearances and behaviors would attract disapproval regardless of whether it was in relation to health care personnel or not. This is why we attribute this similarity across our study and previous similar studies where, socially frowned upon behaviors such as visible and large tattoos, brightly coloured hair, and oddly placed piercings have a more negative impact on the perception of the patient towards the doctor.

The doctor–patient relationship is central to healthcare, and patients' perceptions of doctors’ mannerisms largely depend on how well doctors demonstrate humanistic values in their interactions. According to the results from our study, most respondents also perceive that they can have a good doctor-patient relationship with doctors who exhibit patience, confidence, and compassion as well as appropriate verbal and non-verbal communication. This result supports a similar study done in Malaysia which found that dentists who possessed comprehension as well as empathy toward patients’ problems while examining the patients were preferred more (Ramainor et al., 2021).

Table 5: Association between the demographic characteristics and respondents’ perception on important factor in doctor-patient relationship

In this study respondents with higher education levels were more attentive to mannerisms compared to a less educated person. This finding could be related to the fact that less educated patients considered patient-centered care is too much information and communication (Rademakers et al., 2012). Health literacy plays a crucial role as respondents with higher education levels were more likely to prioritize doctor mannerisms, which could reflect their greater awareness of communication standards and rights within healthcare. While making shared decision for patient management, higher health literacy is crucial to reduce potential risk associated with misunderstanding of health information, misinterpreting treatment options, or failing to engage effectively in management planning (Muscat et al., 2021). Higher health literacy also contributes to increased awareness of patients’ rights, communication standards, and the importance of shared decision-making. Therefore, promoting health literacy across all population groups could improve not only the doctor–patient relationship but also health outcomes and patient satisfaction.

In the meantime, younger respondents (18-30 years) revealed that the manner of the doctors is more important for them compared to the attire to establish a doctor-patient relationship. Meanwhile, the older people in the USA preferred doctors wearing formal attire and donning white coats when compared to the younger respondents (Petrilli et al., 2018). It might highlight the fact that the younger generation is more attentive to mannerisms while the older generation is attentive to physical appearance. This trend might be reflected to evolving generational expectations, especially among Generation Z, who tend to prioritize emotional intelligence, clear communication, emotional expression, and social awareness in interpersonal interactions  (Rothschadl, 2025). Therefore, effective communication, transparency, and emotional support are often more valued than formal attire for Gen Z.

Furthermore, this generational shift may be influenced by the immersion in digital technology, usage of social media and online health content (Rothschadl, 2025; Jiao et al., 2023). Higher exposure to digital platforms and media among Gen Z will be more likely to expect for patient-centered, compassionate, and inclusive care for patients (Grundnig et al., 2022; Schnelle and Jones, 2023).

One of the limitations of the study was that since it was a cross-sectional study, the changes in the perception of patients toward physical appearance and the mannerism of doctors over time is not known. Also, the sample size was relatively small, with most of the respondents being in the age group of 18-25 years, implying that the age groups were not represented equally. Although the questionnaire was presented in two languages, English and Bahasa Melayu, the language barrier would have affected some respondents perceiving the questions. As questionnaires were distributed as a convenience sample, therefore it might limit the generalizability of the findings.

Conclusion and recommendations

The respondents demonstrated increased trust, confidence, and approachability and were more willing to share personal information with doctors dressed in formal attire with a white coat along with name tags. Our findings regarding the preferred attire of the doctor were similar regardless of the doctor’s gender.  The majority felt that ear piercings, nasal piercings, natural hair colours, and short, trimmed nails were more suitable for doctors and short hair in male doctors was more favored. A physician’s ability to portray compassion, patience, expertise, and proper communication was strongly considered as important aspects of mannerism in building up a strong doctor-patient relationship. In general, most respondents felt that both the physical appearance and mannerism of doctors played a significant role in the formation of a good doctor-patient relationship. Mannerism was considered more important for the doctor-patient relationship among younger aged and higher educated people. Therefore, healthcare providers should adapt their communication style to be more patient-centered and emotionally responsive, particularly for younger or more educated patients.

 Future research must be conducted in a hospital setting to acquire more knowledge on whether the physical appearance and mannerism of doctors would influence the doctor-patient relationship. Furthermore, research could be conducted in Malaysia on a wider scale to expand the generalizability of the findings of the study with respect to ethnicity and age. Since our study was one of the few which studied the effect of mannerisms on the doctor-patient relationship, further studies can also be done in this area of research to have a better understanding of how important the mannerisms of doctors are. Based on this study, doctors can also take into account that by wearing formal attire with a white coat and practicing mannerisms such as compassion, confidence, patience, attentiveness, composed and appropriate verbal and non-verbal communication, they are able to form a strong doctor-patient relationship with their patients.

Author contributions

DKB, KR, ATR, DUG conceptualized the study design and collected the data. MLNNH and HHKS conducted the data analysis. DKB, KR, ATR, DUG prepared the manuscript. MLNNH, NN, SM, and TMK reviewed and revised the final manuscript.  

Conflicts of interest

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data sharing statement

Data will be available upon request to the authors.

Acknowledgement

We would like to extend our heartfelt gratitude to all the participants of this study, whose contributions were invaluable to the success of this research. Our deepest thanks also go to Professor Dr. Adinegara Lutfi Abas, Pro Vice-Chancellor of the Faculty of Medicine, Professor Dr. Jayakumar Gurusamy, Dean of the Faculty of Medicine at Manipal University College Malaysia (MUCM), for their continuous support and guidance. Additionally, we are grateful to the Research Ethics Committee, MUCM, for their approval and oversight of this study.

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Appendix: Photographs of various attire in male and female doctors

Below is a series of photographs depicting doctors dressed in four different attires.

Figure 1. Male: (a) Formal attire with white coat, (b) Business attire with coat & tie, (c) Scrubs, (d) Casual attire e.g., T-shirt & jeans

Figure 2. Female: (a) Formal attire with white coat, (b) Business attire with coat, (c) Scrubs, (d) Casual attire e.g., T-shirt & jeans