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A person should wear what he wants to

And not just what other folks say.

A person should do what she likes to—

A person's a person that way.

Free to Be You and Me1

Should physicians have facial piercings? The question, on its surface, may sound trivial, and to many the answer may seem obvious. But within this simple question lie profound tensions, between physicians' individual rights to self-expression and their duty to act in the interests of patients, between cultural or even religious affiliation and membership within the medical profession. Answering this question is not as straightforward as it may seem.

Body piercing in the United States is increasing in prevalence, especially among young adults. A 2001 study found that 51% of undergraduate college students at one university had pierced some part of their bodies (excluding pierced earlobes for women).2 Clearly, the medical profession will soon need to confront the issue of whether visible body piercings are appropriate within its ranks, or at least among its trainees.

General appearance and standards of dress are important issues in our profession. Society has accorded physicians special privileges and status and expects us, as part of a larger “social contract,” to conduct ourselves in accordance with standards that we ourselves regulate but that are driven by the interests of those we serve. For instance, patients prefer and have come to expect physicians to wear a white coat with a name tag and to dress conservatively3–5; this mode of dress conveys respect and gives formality to patient-physician interactions. The medical profession has a vested interest in maintaining this dress code, which, like the uniforms of military personnel and clergy, affords professional identity and the privilege and status that come with it.

Facial piercings, still largely seen as emblems of youth counter-culture, seem inconsistent with professional standards of appearance. The study by Newman et al., in this issue of Journal of General Internal Medicine, confirms this contention.6 In their survey, approximately half of all patients and an even greater proportion of physicians felt that nose and lip piercings were inappropriate for physicians, and more importantly, these piercings appeared to affect patients' trust, comfort, and judgments of physician competence. The study was conducted in a single center in Nashville, TN, where facial piercings may be more or less common than in other cities. However, it is noteworthy that a third of patients who had themselves engaged in body modification (either tattoos or piercings) considered nose rings and lip labrets inappropriate for physicians, suggesting that even patients who probably had no personal aversion to body piercing felt that physicians should adhere to a different (i.e., professional) standard.

These findings are important. Patients are often in a position of vulnerability, as they may be quite ill and depend upon physicians for help and medical advice. Physicians have a responsibility to put their patients at ease, and professional appearance may be part of that responsibility. If patients are made uncomfortable by a physician's appearance, then the physician has a duty to consider changing his/her appearance. Essentially, physicians have duties to act in patients' interests that, in some cases, may supersede their own rights as individuals.

The answer, then, to our original question may seem clear: physicians should avoid wearing nontraditional facial jewelry at work. Before reaching this conclusion, however, it is important to consider that while body piercing may for some be little more than a cosmetic or fashion statement, for others, it holds much deeper significance. Some practitioners of body modification consider their piercings to be a part of their “true,” or originally intended, bodily form.7 Others consider piercings to be a spiritual practice or a rite of passage, through which a person exercises control over his or her body.8 In some parts of the world, facial piercings (e.g., nose piercings among South Asian women) are normative and considered part of one's cultural identity.

Facial piercings, therefore, are not so easily dismissed. In deciding whether or not facial piercings are appropriate in a clinical setting, physicians, medical students, and other health professionals must weigh their own convictions against the potential adverse effects that they may have on their interactions with patients (and, in the case of students, their evaluators). Is the significance of the facial piercing to the individual great enough to warrant the potential negative impact on his/her relationships with patients? Do the individual's personal beliefs about facial piercing preclude removing the jewelry during patient care? Do patients who might not feel comfortable with facial piercings have the ability to see a different practitioner?

To help physicians and students weigh the intensity of their own convictions against those of patients, more research would be helpful. While the study by Newman et al. tells us that a substantial number of patients consider facial piercings for physicians to be inappropriate, it does not tell us how inappropriate. Participants' judgments were based on photographs rather than actual interactions with physicians. In a real encounter, judgments would be influenced by additional pieces of information, for example, whether the physician behaved kindly or communicated effectively. Thus, we do not know the relative impact of piercings on patients' judgments, and whether negative judgments would persist in the face of other assurances of professional conduct.

Another important issue is whether health care institutions, as employers of physicians and other health professionals, have a right to restrict the display of nontraditional facial jewelry. We believe that they do. Health care institutions are businesses whose primary responsibility is patient care, and to the extent that facial piercings negatively impact that care, or even simply patients' perceptions of that care, policies restricting their display may be reasonable. However, such policies must be revisited over time. In the study by Newman et al., patients—particularly younger patients—were more tolerant of earrings on men than other nontraditional facial jewelry.6 This is undoubtedly in part due to the increased prevalence of male ear piercings over the last two decades and their gradual acceptance as relatively mainstream. If other facial piercings become socially accepted over time, restricting their display may be unwarranted.

We also believe that policies restricting facial jewelry must allow for exceptions in individual cases. Patients' preferences are important but are not the only consideration. While most physicians are willing to acquiesce to patients' preferences that they not wear casual clothing (e.g., blue jeans and sneakers), we suspect few would support policies forbidding Muslim women from wearing traditional head scarves—which for many is a matter of deep personal and religious conviction—even if patients expressed strong preferences against them. Where do facial piercings fall on this spectrum? The answer to this question will vary from one individual to the next. A woman recently sued her employer, a large corporation, over a policy forbidding her from wearing an eyebrow ring, stating that the policy constituted religious discrimination, based on her affiliation with the Church of Body Modification.9 While this is an extreme case, it illustrates that for some individuals, the right to display facial piercings is not trivial.

A final consideration is that the overall benefit of allowing self-expression among physicians may be greater than the sum of benefits gained by the individual physicians who are able to self-express. There is inherent value in living in a society characterized by tolerance and freedom, and physicians ought to uphold these values through example. Many physicians who trained in the 1960s and 1970s wore long hair and beards and nonconformist clothing, helping to legitimize “hippie” culture. We must be careful not to purposefully reinforce narrow constructions of how professionals are allowed to appear. Two recent studies found that patients did not like their female physicians to be overweight5 and preferred that they wear dresses.10 Catering in any way to these patient preferences would be tantamount to turning back the clock on civil rights. As a profession, we must consider the value of promoting tolerance for diversity, and not contribute to the marginalization of people simply because they do not conform to our views of normal behavior.

In taking on the professional role of a physician, we are not really “free to be you and me.”1 Physicians engage in relationships with patients, and all relationships require compromise and sacrifice. In the end, decisions about facial piercings and other forms of self-expression must be based on the balance between the preferences of both patients and physicians. Physicians ought to be willing to sacrifice some rights of self-expression for the benefit of patients, but they do not have the obligation to subordinate their entire identity. Each individual physician should consider seriously the importance of his/her own appearance and its ramifications for patient care. Institutions that decide to implement dress code policies limiting specific forms of self-expression should allow methods of appeal that are fair and that do not prohibit principled expressions of cultural identity.

Acknowledgments

  1. Top of page
  2. Acknowledgments
  3. References

Drs. Beach and Saha are supported by Generalist Physician Faculty Scholar awards from the Robert Wood Johnson Foundation. Dr. Saha is also supported by a Research Career Development award from the Health Services Research and Development Service of the Department of Veterans Affairs. Dr. Beach is also supported by a K-08 from the Agency for Healthcare Research and Quality.

The opinions expressed in this paper are those of the authors and not necessarily those of the Journal of General Internal Medicine, the Society of General Internal Medicine, the Robert Wood Johnson Foundation, or the Department of Veterans Affairs.

References

  1. Top of page
  2. Acknowledgments
  3. References
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    Marlo Thomas & Friends. Free to Be … You and Me. Arista, 1972.
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    Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc. 2002;77: 2934.
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    The Church of Body Modification. Available at: http://www.uscobm.com/doctrine.asp?title+Chruch%20doctrine. Accessed January 10, 2005.
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