Dr. Rohini Handa shares his personal opinion about wearing ties at the workplace, the history of the accessory, evolution of dress code for physicians, and the advantages and potentital health hazards of wearing ties.

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To tie, or not to tie, a tie- That is the question!

While the science of medicine requires evidence, the art of medicine does need a wee bit of sartorial elegance to complement the professional experience and add to distinguished eminence. Physicians are taught to abjure 'window dressing' in scientific studies but what about 'dressing up' for work?

As a resident at the All India Institute of Medical Sciences, New Delhi, I was schooled in the belief that neckties were the exclusive preserve of consultants. Surrounded by patients, hounded by beepers (cell phones had not made their advent then), and swamped by scut work, ties were definitely not for the hoi polloi like us.

When I joined the rarefied echelons of faculty, my dress code too changed. Shirts open at the collar were only for the summers. Ties were de rigueur in winters. Medical conferences and seminars were unthinkable without ties. Thus, were spent two decades. Then came the transition to a corporate hospital where the dress code for residents and consultants was more egalitarian. Ties were the de facto if not the de jure dress code for male doctors. And they were a perennial fixture, be it summer or winter.

Change is the only constant in life. Dressing styles are no different. Hats and pocket watches are now considered antiquities from a bygone era. What about the necktie? Of late, there has been a perceptible shift in the attitude towards ties. More and more professionals, doctors included, are forsaking ties for open collars. Jackets without ties are surreptitiously making their advent at formal events.

This piece explores the history of this accoutrement, looks at the dress code of doctors, examines the benefits of ties, and finally touches on the health hazards of ties. The viewpoint is personal. To tie, or not to tie, a tie that is the question.

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Origin of the Necktie

It is believed that the cravat was the predecessor of the present-day tie. The cravat was made popular by the Croatian mercenaries serving in France during the Thirty Years' War (1618–1648). They sported a small piece of cloth around their necks as a part of their uniform. This was adapted and adopted by the French King Louis XIV, and in turn by the nobility. Arguably, the most important legacy to survive this War, this fashion accessory underwent several stages of metamorphosis before assuming the modern-day avatar- the necktie as it is called today. [2]

The intermediate forms that have dotted the neckwear landscape from cravat to necktie include jabots, Steinkirks, stocks, scarves, bolo (bootlace) tie, bandanas, ascots, bow ties, etc. not necessarily in that order. Oscar Wilde, the famous Irish poet and playwright, was as flamboyant in dressing as in real life, and the tie lovers often remind us of his quote 'A well-tied tie is the first serious step in life'. They also celebrate December as the Tie month.

The size of ties, much like the trouser bottoms, have shrunk and expanded over years. From skinny ties to broad ties, some with colourful names like a kipper tie in an apparent reference to a British breakfast fish, the pendulum has swung back and forth. The patterns have also changed like a kaleidoscope from solid colours through pastel shades to floral prints including cartoon characters. Pari passu with tie sizes, the art of tying a knot has been exalted to the realm of exotica. The four-in-hand knot is perhaps the most widely used although some experts reckon there are as many as 85 ways to tie a tie [3]

Over years, the tie came to be accepted as a symbol denoting class, sophistication, and membership of a club, military regiment, or professional association like the Royal Colleges, Indian Rheumatology Association, etc. Those in white-collar jobs were expected to wear ties to work. Bankers, industry moguls, managers, lawmakers, and parliamentarians in the western world, and doctors wore ties every day. Ties also became a part of the school uniform in private elite schools.

As fashion trends changed some intellectuals started questioning the utilitarian value of this fashion accessory. Comfort and functionality started reigning supreme. Start-ups and giant firms like Google, Apple, Ikea, etc. led the pack in eschewing the staid dress codes of the earlier days. Bohemian was in, and polo-neck and round-neck T-shirts invaded the workplace giving stiff competition to the suits and jackets. Keynote speakers at mega meetings came without the tie in tow. The corporate style was dealt a body blow from which it never fully recovered. The Gen alpha is also unlikely to venerate relics of the past.

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Doctors' attire

The professional attire of a doctor has been talked about for ages. This has also been studied. While there is disagreement on the specifics, there is near unanimity that a doctor's attire is important in making a positive first impression. More than half of the 4062 patient responses in a recent study from the United States indicated that physician attire was important to them during care and over one-third agreed that it influenced their satisfaction with care. [4] 

What if the ideal 'professional' look eludes consensus? In this particular study, respondents rated formal attire with the white coat for both male and female physicians as the most preferred form of dress compared with other forms of attire. Interestingly, the age of the patient may influence patient perception with older patients favouring formal dress for their doctors. This is not surprising because cultural norms influence patient preferences.

Physician attire thus emerges as a modifiable variable in the doctor-patient relationship that has the potential to improve patient experience and satisfaction and eventually produce better outcomes

Not only does attire influence the patient, it also impacts the wearer's psychological processes, a phenomenon dubbed 'enclothed cognition' by Adam and Galinsky in 2012 [5] Journal of Experimental Social Psychology. 48 (4): 918–92]. Formal clothing imparts a sense of authority and power. Paternalism is embedded in the traditional practice of medicine. While it may seem anachronistic in the current medical scenario of the west, it continues to be a reality in large parts of India and other countries. Paternalism simply put is the physician making decisions based on what he or she discerns is in the patient's best interests. Formal clothing, especially the tie, is an important symbol of authority in rural India. Patrician the tie may not be, plebeian it certainly is not.

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Health benefits of ties

Except for the closed collar keeping the neck warm, there are no reported health benefits of wearing a necktie.

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Health hazards of ties

In a changing medical environment with heightened awareness about the spread of nosocomial infections, white coats and ties have become the cynosure of attention. Most research has focussed on white coats with some attention also being paid to ties. Several studies have demonstrated that bacteria and pathogens can be isolated from white coats, neckties, and sleeves of medical providers. These have led to the abandonment of white coats in many institutions except by pathologists and other laboratory personnel where the coats stay in the lab. Paediatricians and psychiatrists have been at the forefront of the crusade against white coats. The 'bare below the elbows' policy is an extension of the same ethos. This is by no means universal. While countries like the UK have banned the white coat, it is not so in the US, Australia, or India.

The tie seems to have received flak out of proportion to its size. Ties, since they are infrequently washed, are more likely to cause a spread of infection as compared to other items of clothing that are washed regularly e.g. shirts. A study that included 25 physicians and 25 surgeons demonstrated that the bacterial counts from the ties were significantly higher from ties that were rarely, if ever, cleaned than from shirts that were washed every 2 days or more frequently. [6] 

A study carried out at the Royal Infirmary of Edinburgh that included 40 doctors demonstrated S.aureus carriage by 20% doctors. Of the 40 doctors questioned, more than two-thirds had never cleaned their tie. Patients surveyed in the same study (93%) had no objection to doctors not wearing ties. [7] This led some hospitals to issue a diktat that 'ties act as a vector for transmission of infection; where ties are worn they must be changed daily and tucked away when in contact with patients'.

Other than the potential risk of infection, there have been some studies looking at other health hazards of the necktie. Reduction in cerebral blood flow [8] and an increase in intraocular pressure by tight neckties [9] has been reported. The clinical applicability and generalisability of these findings are uncertain. There is no research available on the health impact of ties in hot humid tropical conditions versus cold climates.

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COVID-19 pandemic and ties

The COVID-19 pandemic has generated a lot of brouhaha about the transmission of the coronavirus by inanimate objects. To date, there is no convincing evidence that ties play a role in the transmission of the coronavirus. However, this pandemic has spawned a problem of another kind. As the acceptance and penetration of online consults have skyrocketed, the necessity to dress formally has plummeted. The tie has been the first casualty of this changing consultation environment from physical to virtual. Whether it will recover from this body blow, only time will tell.

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Denouement

Dressing up for one's job, which for us doctors is seeing patients, will never become outdated. Dressing neatly will also always remain timelessly pertinent. The style may change, the substance-a professional sober look- will not. Ties will continue to have panegyrists and detractors.

As articulated by a tie aficionado in Forbes:

"Despite various attempts to kill them off over the years – by turtleneck-wearing intellectuals, laid-back Silicon Valley types, and the recent 'corporate casual' movement – neckties endure."

The opponents call neckties "socially desirable strangulation" or "the corporate noose". Wear it or forsake it, love it or hate it, ignore it you cannot. It is the quintessential Gordian knot.

I, for one, now wear ties occasionally- more to break the monotony than as a mandated dress code for consultants. Convention has yielded to comfort. I leave it to you to decide what you want. To each his own.

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This article was originally published on 8 January 2021.

The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Rohini Handa is a Senior Consultant Rheumatologist from Delhi.