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I’m asked more frequently about my preference in neckwear than just about anything else when I’m seeing patients in the hospital or the clinic. I thought that a small detour from our discussion of more weighty matters in science and medicine would give me an opportunity to offer an explanation.


Allow me to start at the very beginning. I do not come from a bowtie tradition (Although Grandpop Shulman does have a couple of choice ones, possibly dating from the early ‘60s because they look like the ones on “Mad Men.” One of them is a favorite in my rotation). My dad’s closet was full of the dark suit separates, white shirts, and dark ties that identified him as an IBM systems engineer. Wearing the bowtie is not an exercise in political self-identification. Whenever someone assumes that I am a conservative Republican because of the bow around my neck, I remind them that Southern Dems, and even northerners like Senator Paul Simon of Illinois, all rocked the bowtie.


I clumsily tied my first bowtie in an effort to look less like a kid playing dress up in his dad’s clothes when attending college formals. At the time I was improving my bowtie technique, I visited my big sister Deb at Oxford when she was a Marshall Scholar at Magdalen College (needless to say, Deb is the scholar of the family). I saw a gorgeous checker-print tie at Ede and Ravenscroft, Royal Robemaker. It was too much to resist, after all, I had just made a pilgrimage to visit Sir William Osler’s home. I started to occasionally wear the bowtie outside of formal occasions.


In July, 2004, I started my first clinical rotation of the third year of medical school, family practice at John Peter Smith Hospital in Fort Worth, Texas. It was then as it is now in Texas, really hot. Absurdly hot. Anxious to look the part, I showed up for the first several days wearing  a polyester dress shirt, necktie, and the polyester white coat that had laid dormant for the three years that I was in the lab working on my PhD. The pockets of the white coat were laden with med student survival guides, note cards, stethoscope, reflex hammer… what I really needed was missing – salt tablets to stave off passing out on rounds. I quickly realized that with the constant hand washing and my initial patient exams, I needed to keep the white coat buttoned in order to keep my tie from dragging on patients and soaping up sink water. I can’t emphasize enough how hot it was, the buttoned white coat was like a reflective aluminum-lined strait jacket. Going sans-white coat was not an option in my traditional medical school. The short white coat allowed me to be immediately classified in my proper place at the bottom of the hospital hierarchy.


After the first several days, I realized that I was not going to make it through the rotation without some way of encouraging ventilation. I reached for the yellow-orange checkered English bowtie and rounded on diabetics and COPDers with my white coat unbuttoned. I was probably only 2 liters of fluid down by the end of the day, a dramatic improvement. There was no looking back, I was a bowtie man.


What started as an effort at summer survival slowly took on a life of its own. Friends and family started to send me bowties on my birthday. My adopted medical school class started to expect them. I’ll admit that in a medical culture that was focused on uniformity and excellence, and not so much on individualism, the bowtie seemed to work as a non-subversive touch of personal flair.


My bowtie run continued with my debut as an intern at Children’s Hospital Boston. Pediatricians typically avoid the white coat and the disconcerting effect that they can have on wizened kids. Despite the traditions of the “Department of Medicine” at Children’s, of the say 15 other guys in my intern class, only about half wore ties as standard attire. At first, I was the only person at CHB under the age of 60 wearing bowties, the hospital’s clown corps included. As I gained experience working with kids, I learned that less neckwear meant less choking hazard. Best of all, people don’t realize that tying a bowtie is so much easier than tying a necktie. It is just two simple overhand knots, the bow shaped by feeding the tie held between the thumb and forefinger of the right hand behind the knot to the left hand (instructional movie here). Completely avoided is the challenge of judging the length of the necktie so that it comes out not too long, not too short, but just right. Since I am habitually late, I often compose a near-perfect knot while stopped at a red light on Turtle Creek on my way to clinic at Scottish Rite Hospital. As I was leaving Longwood, some friends at Children’s started a new bowtie Friday (or was it Thursday?) tradition. I was pleased that others were seeing the light.


My bowtie preference was in no way data-driven, but of course I would be remiss if I failed to refer to the growing body of literature that suggests that neckties dragging along patients and bedding can become a conduit for nosocomial (hospital-acquired) infection. The British National Health Service was moved to adopt a “bare-below-the-elbows” (which sounds kind of racy) and tie-less dress code in September of 2007. What kind of attire do patients expect their doctors to wear? A classic 1987 JAMA article that polled patients at Longwood’s Brigham and Women’s Hospital and UCSF’s Moffitt Hospital reveals that 65% of patients expected white coats and 37% felt that male physicians should wear ties. More recent surveys suggest that scrubs are OK and that white coats and ties are not expected. Most interesting, patient responses indicate that they rely on attire as a way of identifying the people who keep coming in to their hospital rooms. They would like clothing to identify who their doctors are and as medical teams become larger and more varied, who is running the show.


I suppose that I am a bit old-school in thinking that the necktie is a symbol of professionalism for male physicians. I think of how my dad stubbornly continued to wear his white dress shirts, painstakingly ironed by my mom, even when “dress-down Fridays” came into vogue. He explained to me that he was a professional, would dress like a professional, and would be treated like a professional.  Some feel that the bowtie connotes intellectual elitism and that its wearers are contrarians that would prefer to inhabit the past, kind of like Owen Wilson’s character in Woody Allen’s new “Midnight in Paris.” I plead somewhat guilty to this charge but would respond that bowties are worn by academics but are also worn by waiters and busboys. The same conveniences that directed me toward the bowtie explain why the bowtie is the classic neckwear of those who serve. Being a resident is much more similar to working as a waiter in a packed room full of hungry diners than it resembles the image of a professor at the lectern. I like to think of the bowtie as a symbol of the ethic of humble service.


When people, kids and their parents, see my bowtie, they tend to smile. I notice this at least once a day and smile back. There is nothing like a shared smile to get things off on the right foot. As long as people keep smiling, I’ll stick with the bowtie.