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research-article2015
CPJXXX10.1177/0009922815616889Clinical PediatricsJohnson et al

Original Article
Clinical Pediatrics

Adverse Effects of Tattoos and Piercing 1­–6


© The Author(s) 2015
Reprints and permissions:
on Parent/Patient Confidence in Health sagepub.com/journalsPermissions.nav
DOI: 10.1177/0009922815616889

Care Providers cpj.sagepub.com

Scarlett C. Johnson, MS1, Maegan L. M. Doi, MS1,


and Loren G. Yamamoto, MD, MPH, MBA1

Abstract
First impressions based on practitioner appearance often form the basis for preliminary assumptions regarding trust,
confidence, and competence, especially in situations where patients or family members do not have an established
relationship with the physician. Given their growing prevalence, we strove to further investigate whether visible
tattoos or piercings on a medical provider affects a patient’s perception of the provider’s capabilities and their trust
in the care that would be provided. A survey using photographs of simulated practitioners was administered to
314 participants split between rural and urban locations. Study volunteers rated tattooed practitioners with lower
confidence ratings when compared with nontattooed practitioners and reported greater degrees of discomfort with
greater degrees of facial piercing. We concluded that these factors adversely affect the clinical confidence ratings of
practitioners, regardless of the gender, age group, or location of participants.

Keywords
patient confidence, physician appearance, provider tattoo, provider piercing, patient trust

Introduction as significant as professional attire, up to 30% of family


members of intensive care unit patients stated that the
The manner in which physicians present themselves can absence of visible tattoos was important when first
have an effect on the doctor-patient relationship via the meeting the physician.1 Although tattoos were found
patient’s or family members’ perception of the provider, predominantly on military personnel in the 1940s, they
especially in high-intensity first encounters such as the have become more popular. Their presence might lead to
intensive care unit setting1 or emergency department. perceived social characteristic associations.21 Some hos-
First impressions often form the basis for preliminary pitals have adopted employee policies restricting visible
assumptions regarding trust, confidence, and compe- tattoos or nontraditional piercings, to maintain an out-
tence, especially in situations where patients or family ward appearance of professionalism, a core component
members do not have an established relationship with in establishing a patient or family member’s trust and
the physician. confidence. However, the practice of having tattoos has
Previous studies have shown that patients consider increasingly become more mainstream, and national
bedside manner, including speech, rapport, and personal- surveys suggest 24% of people aged 18 to 50 years are
ity, to be highly important when assessing physicians.2-6 tattooed.21 A 2006 survey found that among Americans
Another way in which physicians present themselves to born between 1975 and 1986, 36% had at least 1 tattoo,
patients is their appearance. Many studies have found 32% had a nontraditional body piercing, and 20% had
attire to be a significant factor when assessing physi-
cians,1,2,4,7-16 especially in more acute settings, though a 1
few studies did not find a preference based on attire.6,17-19 University of Hawai’i John A. Burns School of Medicine, Kapi’olani
Medical Center for Women and Children, Honolulu, HI, USA
While the significance of attire has been studied in
numerous settings, there are fewer studies about the Corresponding Author:
importance of other aspects of physician appearance, Scarlett C. Johnson, Department of Pediatrics, University of Hawai’i
John A. Burns School of Medicine, Kapi’olani Medical Center
such as the presence of tattoos and piercings.1,12,16,20 for Women and Children, 1317 Makiki Street, Apartment #202,
Tattoos can be a prominent factor in one’s appear- Honolulu, HI 96814, USA.
ance. A 2013 study survey found that, though not ranked Email: scj@hawaii.edu

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2 Clinical Pediatrics 

both tattoos and piercings.21 Facial piercings—espe-


cially nose and eye brow rings—appear to be detrimen-
tal to establishing patient confidence and trust in a
provider, especially among older populations.12,16,20
The purpose of this study is to further investigate whether
the presence of visible tattoos or piercings on a medical pro-
vider affects a patient’s perception of the provider’s capa-
bilities and their trust in the care that would be provided.
Figure 1.  Sample front and side views of neck tattoo.
Materials and Methods
Adult volunteer study subjects were surveyed at public Study subjects were then asked if they preferred one
parks in 2 locations in Hawai’i. Hilo is a small city on provider over the other. With each survey, we alternated
the Big Island with a population of 43, 263 in 2010.22 which provider had the tattoo, as well as whether the
Honolulu is a large city on Oahu with a population of provider with the tattoo was located on the top or bottom
991, 788 in 2014.23 Potential study subjects were of the board (4 different combinations). Figure 1 shows
approached to see if they were interested in participating the tattoo locations on the front and side views of one of
in the survey. If interested, they were provided with a the providers. Both providers had the same tattoo pattern
study information sheet describing this as a study of in the same location.
health care provider appearance. Our initial survey Study subjects then viewed 3 drawings of a hypo-
introductory description and the information sheet did thetical provider with a large ear ring, nose ring, or both
not specifically mention tattoos or piercings. ear and nose rings (Figure 2), and rated their clinical
Study subjects were interviewed one at a time by one confidence on a 4-point confidence scale:
of the study investigators. They were shown a board with
randomized photos of 2 different male “medical provid- 1. This would make me very nervous, and I would
ers” (front view and side view of each), who were medi- not trust the care and advice from this medical
cal student classmate volunteers with identical dress, one provider.
of whom had a tattoo on his neck and the other without a 2. This would make me slightly nervous, and it
tattoo. Study investigators specifically avoided the men- would lower my trust of the care and advice
tioning of the tattoo in one of the pictures to reduce any from this medical provider.
biasing or focusing on the tattoo. In other words, the study 3. This would not bother me at all. I would fully
subject would have to notice the tattoo on their own with- trust the care and advice from this medical
out any prompting if this was going to affect their prefer- provider.
ence or confidence rating. They were provided the 4. This would make me trust the care and advice
following scenario: “Imagine your 2-year-old child devel- from this medical provider more so than if these
ops a fever of 104°F. You take him to a nearby urgent care weren’t present.
center where you see the 2 providers held up before you.
The provider on the top begins the process of examining Data were analyzed according to gender (male vs
your child. What do you think of him thus far?” They then female), age of the study subject (<35 years vs ≥35 years
rated their clinical confidence on a 4-point confidence and <50 years vs ≥50 years) and population density site
scale (below) before answering the same question for the (Hilo-rural or Honolulu-urban). Paired clinical confi-
second provider on the bottom of the board. dence scale scores (tattooed provider’s scores vs the
nontattooed provider’s scores) were compared using a
1. I am so nervous about this medical provider’s paired t test.
ability that I am thinking of walking out and
going to a hospital ER 15 minutes away.
Results
2. I am uncomfortable with this medical provider
but I will stay and have my child checked by A total of 314 surveys were completed during the study
him. period 2014 to 2015 with 157 participants at both loca-
3. I am comfortable with this medical provider and tions. Fifty-three percent were female, 35% were
having my child checked by him. younger than 35 years, and 40% were 50 years or older.
4. I am very confident in this provider, and I trust Clinical confidence scores for tattooed and nontattooed
the treatment that he recommends. providers are summarized in Table 1. Regardless of

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Johnson et al 3

Figure 2.  Drawings of large facial piercings.

Table 1.  Clinical Confidence Scale Scoresa for Tattooed Versus Nontattooed Providers.

Mean ± SD Clinical Mean ± SD Clinical


Confidence Score in Confidence Score in
N Tattooed Provider Nontattooed Provider Difference P
All 314 2.80 ± 0.73 3.11 ± 0.63 0.31 <.001
Females 167 2.85 ± 0.74 3.14 ± 0.62 0.29 <.001
Males 147 2.75 ± 0.72 3.08 ± 0.65 0.33 <.001
Age (years)  
 <35 113 2.88 ± 0.72 3.08 ± 0.68 0.19 .005
  ≥35 201 2.76 ± 0.74 3.13 ± 0.60 0.37 <.001
 <50 175 2.86 ± 0.72 3.11 ± 0.68 0.26 <.001
  ≥50 139 2.73 ± 0.75 3.11 ± 0.56 0.37 <.001
Rural (Hilo) 157 2.81 ± 0.79 3.15 ± 0.61 0.34 <.001
City (Honolulu) 157 2.80 ± 0.68 3.07 ± 0.65 0.27 <.001
Clinical confidence score frequencies for tattooed and nontattooed providersa
1 = walking out, going to ER 18 (6%) 7 (2%)  
2 = uncomfortable with provider 67 (21%) 26 (8%)  
3 = comfortable with provider 188 (60%) 206 (66%)  
4 = confident in provider 41 (13%) 75 (24%)  

Abbreviation: ER, emergency room; SD, standard deviation.


a
1 = I am so nervous about this medical provider’s ability that I am thinking of walking out and going to a hospital ER 15 minutes away. 2 = I
am uncomfortable with this medical provider but I will stay and have my child checked by him. 3 = I am comfortable with this medical provider
and having my child checked by him. 4 = I am very confident in this provider, and I trust the treatment that he recommends.

gender, age, and location, the nontattooed provider had board rather than on the bottom (P = .009). Despite this,
a higher mean clinical confidence score compared with the top/bottom position was randomized eliminating this
the tattooed provider. Eighteen subjects (6%) found that as a factor for the differences between the tattooed and
the tattooed provider made them so nervous that they nontattooed provider scores. When asked which pro-
would walk out of the urgent care clinic to drive to an vider they preferred, 9% preferred the tattooed provider,
ER 15 minutes away, while only 7 subjects (2%) felt this 33% preferred the nontattooed provider, and 58% had
way about the nontattooed provider. Seventy-five sub- no preference.
jects (24%) felt very confident in the nontattooed pro- For the providers with piercings, the mean clinical
vider, while only 41 subjects (13%) felt very confident confidence scores and frequencies are summarized in
in the tattooed provider. Table 2. Regardless of gender, age, or location, the high-
In testing for other effects, we found no significant est mean confidence score was for the provider with the
preference based on which provider was tattooed ear piercing and the lowest score was for the provider
(P = .848), but there was a significant preference for with both ear and nose piercings. Study subjects rated the
choosing the provider located on the top position of the provider as “not trusted” 21% of the time for the ear ring

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4 Clinical Pediatrics 

Table 2.  Clinical Confidence Scale Scoresa for Facial Piercings.

Mean ± SD Clinical Mean ± SD Clinical Mean ± SD Clinical


Confidence Score for Confidence Score for Confidence Score for
Provider With Ear Provider With Nose Provider With Nose
N Piercing Piercing and Ear Piercing
All 314 2.27 ± 0.84 1.99 ± 0.83 1.90 ± 0.85
Females 167 2.31 ± 0.83 1.99 ± 0.85 1.92 ± 0.87
Males 147 2.21 ± 0.84 1.99 ± 0.82 1.88 ± 0.83
Age (years)  
 <35 113 2.57 ± 0.77 2.19 ± 0.79 2.06 ± 0.85
  ≥35 201 2.09 ± 0.83 1.87 ± 0.84 1.81 ± 0.84
 <50 175 2.49 ± 0.77 2.17 ± 0.80 2.06 ± 0.86
  ≥50 139 1.99 ± 0.83 1.76 ± 0.83 1.78 ± 0.83
Rural (Hilo) 157 2.24 ± 0.83 2.02 ± 0.84 1.97 ± 0.85
City (Honolulu) 157 2.29 ± 0.85 1.95 ± 0.83 1.83 ± 0.86
Clinical confidence score frequencies for each piercing categorya
  Ear ring only Nose ring only Both ear and nose rings
1 = would not trust 67 (21%) 106 (34%) 124 (39%)
2 = lowered trust 108 (34%) 111 (35%) 104 (33%)
3 = fully trust 127 (40%) 92 (29%) 79 (25%)
4 = prefer piercing 12 (4%) 5 (2%) 7 (2%)

Abbreviation: SD, standard deviation.


a
1 = This would make me very nervous, and I would not trust the care and advice from this medical provider. 2 = This would make me slightly
nervous, and it would lower my trust of the care and advice from this medical provider. 3 = This would not bother me at all. I would fully trust
the care and advice from this medical provider. 4 = This would make me trust the care and advice from this medical provider more so than if
these weren’t present.

provider, 34% for the nose ring provider, and 39% for the they might be in other communities. Additionally, the
provider with both the ear and nose ring. When added to tattoos were not specifically identified for the study sub-
the subjects who rated these providers as “lowered trust,” jects who would have to have noticed the tattoo on their
the sum exceeds 50% indicating that there is substantial own for this to affect their confidence rating and provider
degradation of trust in the provider with these. preference. We chose a tattoo size that was not exces-
sively large and glaring, but one that we thought would
be subtle, yet noticed, to study a more realistic scenario.
Discussion It is likely that the magnitude of the differences could be
This study shows that in the clinical setting described, proportional to the size and noticeability of the tattoo.
participants prefer providers caring for children to be Numerous study participants in Hilo, a relatively
without visible tattoos or large piercings and that such rural area with a more severe physician shortage, chose
factors lower their confidence in a provider’s capabili- to share that they would be happy with any physician
ties. This preference was seen regardless of the gender, given how hard it was to find one. However, even in
age group, or location of participants. However, the mag- Hilo, our results showed a negative impact of tattoos and
nitude of these score differences was small, as measured large piercings on participant confidence in a physician.
by the scale used in this study setting, raising the issue of This supports the findings of a previous study that
statistical significance versus clinical importance. although patients may state that they have no preference
Considering that Hawai’i is generally considered to be a about certain aspects of physician appearance, attire
diverse state with several ethnic populations having cul- may still have an impact on their comfort and confi-
tural tattoo practices, a more liberal view of acceptable dence with a physician.15
physician appearance might account for this lack of an The piercing results in this study are only applicable
overwhelming difference. As seen in a previous study to the drawings used and cannot necessarily be applied
done in Hawai’i, the majority of participants approved of to smaller, subtler, and more common piercings. The
physicians wearing scrubs and blue jeans, and 52% pre- pictures used were meant to be neutral of age, ethnicity,
ferred physicians to not wear a white coat.9 This consid- and gender; however, a line drawing of a person that
eration suggests that our results are less dramatic than excludes hair and eyes results in an image without a

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Johnson et al 5

“personality,” which has been shown to be an important comparisons to determine if these results are indeed
aspect of a high-quality doctor.3 Of note, large piercings unique to Hawai’i. A limitation of this study is that since
may pose a personal safety risk given their chance of surveys were conducted in public parks and not in an
snagging or being grabbed and were often described by actual medical setting, the hypothetical situation might
our study subjects as potentially “unhygienic.” have felt less acute than was expected of the given sce-
Health care institutions and training programs may nario. In addition, the beach park surveyed in Honolulu
prefer employees and trainees without tattoos and large is one often frequented by tourists and may have resulted
piercings due to a perceived association with unprofes- in the urban sample being less representative of Hawai’i
sionalism and a possible detrimental effect on patient/ than presumed.
family perception of provider competence. For existing In conclusion, tattoos and piercings adversely affected
employees/trainees, they are faced with options such as the clinical confidence ratings of practitioners, regardless
forbidding tattoos/piercing, requiring that tattoos be of the gender, age group, or location of participants.
covered up, or simply permitting them. As tattoos and
piercing become more common, such hiring restrictions Author Contributions
may further limit the size of the workforce applicant All authors were involved in the study design, literature
pool. In many areas, there is already a provider shortage, review, data analysis, data interpretation and revision of arti-
and such limitations will worsen the shortage. Yet regu- cle. SCJ and MLMD were also responsible for data collection
lating dress and appearance is much more operationally and drafting of the manuscript.
feasible than regulating bedside manner. Practitioner
appearance can influence patient satisfaction, which Declaration of Conflicting Interests
appears to be a critical factor in determining how patients The author(s) declared no potential conflicts of interest with
perceive care quality and their decisions to sue practitio- respect to the research, authorship, and/or publication of this
ners in the event of a poor outcome.11 With the growing article.
trend toward consumerist medicine and the impact phy-
sician appearance can have on a patient’s comfort and Funding
establishment of a patient-provider relationship, it may The author(s) received no financial support for the research,
be wise to make conservative choices so as to not risk authorship, and/or publication of this article.
displeasing or offending patients. Given that this study
confirms the adverse effects of tattoos and piercings on References
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