The tattooed doctor: An exploration of the perceptions of medical students and medical school staff

Objective: This study explored the perceptions of medical students and medical school staff towards tattoos. Background: As tattooing continues to become more of a mainstream practice, and with the lack of clarity provided by the General Medical Council on the topic, research to inform policy makers at a national and local level is merited. Methods: A case study was implemented to facilitate the exploration of the perceptions of tattoos. Focus groups and semi-structured interviews were used for students and staff respectively for data collection. The results underwent thematic analysis according to Braun and Clarke’s guidance. Results: Medical students and medical school staff had broadly similar perceptions of tattoos. Four main themes were identified: the nature of tattoos, professionalism, freedom of expression and generational perceptions.

Within the medical context, the subject of tattoos is complex. This is because the professionalism of a healthcare provider who wears a tattoo has not yet been defined. Without this definition, it is difficult to understand how a medical professional balances their self-expression against their professional identity. The existence of these conflicting, paradoxical perceptions highlights the interest in exploring the balance between a doctor having autonomous control of their self-expression through becoming tattooed whilst maintaining their professional identity. Cruess et al. (2015) expressed that promoting students to reflect on external influences, such as the opinions of peers, may contribute to the formation of their professional identity because they will have a more in-depth idea of who they wish to be. Encouraging this with regards to tattoos may enable medical students and doctors alike to reflect on what type of tattoo is fitting to allow their professional and personal identity to be harmonious yet distinct. Yet, in an era set to diversify the medical population and encourage people from wide ranging credentials to achieve their potential in a rewarding career (Department for Education, 2017). What might this mean with respect to improving transparency of widening participation practices and ensure applications to the most selective higher education institutions are not tempered by such concepts of self-expression that tattoos portray?

Methods
This study positions itself as being qualitative and exploratory in nature. To fulfil the aims of the research, a case study was implemented to view a "snapshot" of the current perceptions of tattoos within the University of Dundee medical school. A case study can be implemented as a research method when investigating a topic with the intent of ascertaining the understanding that a group or organisation direct towards a phenomenon (Yin, 2014). This study's objective was to survey the perceptions of specific individuals, within a defined context, towards a certain topic. Going by this premise, a case study-based approach was suitable. Focus groups were chosen as the method of data collection for medical students whilst semi-structured interviews were implemented with staff. Four focus groups were performed whilst six interviews happened. The number of focus groups was pre-determined and aligned with literature's recommendations whereas the number of semi structured was not pre-conceived and was left open-ended until saturation occurred. For this research, a convenience sample (Robsinson, 2013, p.32) was selected because in a time restricted study, the researcher wanted to maximise participant recruitment.
The focus groups and interviews were transcribed in a verbatim manner and were then thematically analysed in accordance with the guidance put forth by Braun and Clarke, 2006. By inductively coding the transcripts, the content of the data could drive the analysis.
For the reader of a qualitative study, having an appreciation of how the researcher reduced their own personal bias is crucial to appreciating the trustworthiness of a piece of research (Symon and Cassell, 2012). In this instance, because the researcher was exploring a topic qualitatively within an organisation that they attend, the value of reflexivity became apparent. Reflexivity may be described as the critical self-evaluation of the researcher's stance within a research project where there is an acceptance that such a stance may affect the outcome of the study (Berger, 2013). With the researcher being the primary method of data collection in this study, a strategy to ensure that the researcher would not guide their participants was necessary. An interview/focus group guide, designed using literature from other sectors, on the perception of tattoos would be helpful to ensure no bias was present; coupling this with the introduction of reflection into research practice, the aspect being studied was more closely examined for any assumptions or preconceived ideas that the researcher may have held (Watt, 2007).
Prior to the study beginning, it was vital for the researcher to be aware of ethical standards at a local level but also nationally. An application for ethical approval was submitted and approved by the School of Medicine Research Ethics Committee (SoMREC). Additionally, the British Educational Research Association ethical guidelines were considered (British Education Research Association, 2011). As this study had no contact with patients, it was determined unnecessary to seek approval from an NHS ethics committee.

Results
Four themes and several accompanying subthemes emerged from the data. The major evaluative themes were: Nature of tattoos Professionalism Freedom of expression Generational perceptions The themes and subthemes are organised and displayed in Figure 1 below for reference.  An initial question was asked of both participant groups to determine what they think about when they consider a tattooed individual. This helped to gauge a generalised perception of tattooed individuals and allowed the participants to reflect outwith the medical context.
A few students expressed that they still associated tattoos with specific demographics of people: "…it's always like the bad guys or the rough yins who have got tonnes of tattoos…over their body, and…although you may not agree with that stereotype, it's difficult to…get that idea out of your head, I think." On the contrary, other students expressed that they possess no stereotypes or preconceived ideas towards tattooed individuals: "I think it's a way of self-expression, I wouldn't probably react any different to them wearing a certain item of clothing or them having their hair dyed a certain colour. It's just…a way of them expressing their personality." Similarly, several members of staff shared that they do not associate those who are tattooed with specific stereotypes. However, most acknowledged that stereotypes exist: One member of staff informed that it was not just the presence of a tattoo that formed their judgement of a person. Rather, "it's the overall presentation of the individual" Nature of tattoos: Both medical students and medical school staff identified the nature of the tattoo to be a determinant in their perception of an individual. Interesting points raised firstly encompassed the depiction of a tattoo.
"As long as it's not something blatantly offensive or something that is liable to offend certain parties, then it should be fine."

"I don't think that doctors should have tattoos which display something…upsetting or offensive to other people...I don't think they should have sexually explicit tattoos…tattoos which are marking them out as intentionally being affiliated to something that would be inconsistent with… GMC-type values of a doctor."
Medical students and medical school staff largely agreed that the depiction of a tattoo was important, however, there were discrepancies in opinion as to whether a policy should be implemented.
"I suppose there is the possibility that if you were to allow all tattoos, then you could have very overt and threatening stuff appearing and that needs mitigated to some extent." "It would almost be pointless, to say what you can and can't have. Everything could offend anyone, especially…in this day and age." Both students and staff recognised that the location of a tattoo may be a variable that could influence their perception of a tattooed individual.
"If you have tattoos that basically cover your head and face…then I think that… has the potential to significantly impact…your role." "There is still a line in presentation… I don't think that a tattoo on your face, or anywhere on your hands, would be at all appropriate for a doctor to have." Professionalism: The professionalism of a tattoo was considered by both medical students and medical school staff. Both cohorts expressed that they felt that the presence of a visible tattoo could deter from a doctor's professionalism. Moreover, students and staff articulated that a tattoo could be a barrier to communication whilst also posing a challenge to the patient-doctor relationship.
"I think just…the… social aspect of being able to look at someone's face and see the expression but it's now…marred…by a big tattoo." "I think it might be a bit weird at first because obviously, it's not the norm for medical students to have tattoos and for doctors to have tattoos which you can see." Conversely, some students did not think that a tattoo would pose any issues to a doctor's professionalism.

"yeah, like, if I saw someone with tattoos, I wouldn't think it affected their professionalism at all."
Prevalent in the discussion regarding the professionalism of a tattoo was the concept that a doctor or medical student wearing a tattoo was just one part of a clinical situation of which there are multiple variables that may influence the success or failure of that interaction. By this, some participating members of staff were implying that if "everything else" was to the expected standard, then the presence of a tattoo would not be detrimental. However, there was a contrary to this in that if say the communication skills were not as expected, then the tattoo may play more of a role.
"…somebody who is unprofessional…attitude not right for the area of practice they are working in, then…I almost think you could have skewed vision because of what you are seeing..." Freedom of expression: A number of students commented saying that doctors should be allowed to express themselves in whichever way they please just as other members of society do. Some staff also expressed a similar opinion.
"I personally think they should be allowed to do what they want because they are…people as well as doctors" In opposition, some students and staff appreciated the value in freedom of expression but that it may need monitored somehow: "You want freedom of expression but, at the same time, you need to protect individuals from being offended or being intimidated." Generational perceptions: One of the main, overarching themes identified was the concept of tattoos being subject to generational perceptions. Students and staff made assumptions regarding how they felt specific patient groups would perceive tattoos, commenting on how tattooing practices have changed. Additionally, both medical students and medical school staff remarked how their own opinions of tattoos had changed over time. A few clusters of ideas were also identified.
Some participants felt that a tattoo was unprofessional because of the patient perceiving it in that way. The assumptions regarding the negative patient perception were as follows: "And again, if you consider…the…elderly population as a whole, I imagine that they probably aren't the biggest fans of tattoos and have this pre-empted idea or stereotype of what that person is gonna be like before you've even opened your mouth." Students and staff both discussed how the purpose of tattoos has changed since older generations were young:

"I think tattoos have changed a lot over time, so in my mum's generation…having a tattoo was…a class thing or an occupational thing so…her view of tattoos is that it's what manual workers and people who have been in prison have. Whereas it is just not true anymore…my sister-in-law who is a GP has a tattoo…"
Inclusive of both participant groups was the comment that their opinion towards tattoos has changed over time. Students discussed this because of tattooing becoming a more mainstream practice: Staff also spoke about their opinion changing over time but this came from more of a clinical slant after years of working with the public: "…maybe in years gone past, I would have been surprised at someone who…is a lawyer…and would undress and I would think "oh, I wouldn't have expected that of you". So I think my experience of people and tattoos and my opinion of them has changed definitely over the years…"

Discussion
The initial questioning of both students and staff was performed to understand their overall perception of tattooed individuals. The aim was to discern any stereotypes or preconceived ideas that may still exist within contemporary times.
Several students, despite the "tattoo renaissance" (Mun et al., 2012, p.134), reported having preconceived notions of tattooed individuals. The connotations discussed were negative, permitting the work of Zestcott et al. (2018) to resonate; they highlight that despite the shift of tattoos to a more mainstream practice, explicit and implicit negative attitudes towards tattooed individuals continue to exist.
Nevertheless, the concept of the "tattoo renaissance" cannot be disregarded. The results also underscore that many participants no longer stereotype tattooed individuals, confirming societal awareness of tattoos not being confined to specific socio-demographic groups any longer (Wohlrab et al., 2007). No student or member of staff stated that a doctor or medical student should not be allowed to have a tattoo. Whilst young people may be more malleable to sociocultural influences, resulting in more tattooed youths (Hill, 2016), intriguingly, it was only students who still possessed stereotypes. From this, it could be hypothesised that life experience may mould one's perception. All staff participants had clinical experience which may have shaped their perceptions; to uncover if this reasoning is accurate it would be interesting to track medical students as they transition into clinical practice to evaluate whether their perceptions of tattooed individuals change.
Policies have been created for piercings in the healthcare setting (Southern Health -NHS, 2015) because they can pose a risk to the wearer as well as the person being cared for. When a piercing is healing, it is classified as an open wound and it may become colonised with bacteria (Nazarko, 2014). What appears to have been neglected is similar attention for tattoos; whilst a tattoo may not offer a direct vessel for the carriage of bacteria, there may be other risks. Tattooing leads to traumatisation of the skin that may facilitate bacteria infiltrating the epidermal barrier, with the worst outcome being severe infections (Dieckmann et al., 2016). Coupling this with the knowledge offered by Jafari et al. (2010) that becoming tattooed increases the risk of developing hepatitis B, hepatitis C and human immunodeficiency virus (HIV) may indicate that further guidance is required, especially during the healing phase but also latterly in terms of future infectious diseases risks.
All participants considered the depiction of the tattoo, the consensus being that no tattoo for a medical student or doctor should cause offense or go against GMC values of a doctor. Within Good Medical Practice (GMC, 2013), no stance is found on tattoos. The GMC informed the researcher that they have no position on tattoos; rather, it is a matter for the tattooed individual and their employer. Nevertheless, they still expect doctors to practice according to the guidance of Good Medical Practice (GMC, 2013). This creates potential complacency because of NHS health "We would ask that staff with tattoos that are visible (e.g., forearms) are covered up if they could be deemed inappropriate or offensive." (NHS Shetland, 2012) Conversely, NHS Tayside provides no guidance. The nature of working in healthcare can result in doctors working across different health boards and even medical students having placements with a variety of health boards. For example, students at the UoD medical school attend NHS Highland organisations for placements. Resultantly, it could be surmised that creating a national standardised guideline on tattoos for NHS Scotland would be beneficial.
The location of a tattoo was cited as a determinant of perceptions amongst both participant groups. Buttle & East (2010) noted that facial tattoos may affect the communicative nature of the face whilst Timming (2016) proposed that facial tattoos may deter from the 'aesthetic branding' of an organisation. Although the NHS and the UoD do not have an 'aesthetic brand' for their employees or students, they do share the aim of delivering professional healthcare. With both participant groups advising that a facial tattoo has the potential to appear unprofessional or impact a doctor's role, it is difficult to envisage healthcare being delivered in the vision of the RCP (Tallis, 2006). Hence, it potentially becomes difficult to strike a balance between allowing doctors and medical students full control over their personal identity if their professional integrity may be jeopardised by having a facial tattoo.
Just as with the location of a tattoo, both cohorts conveyed their negative perception of facial tattoos and communication. They commented on the potential implication to a practitioner's communication if their facial expressions were to be "marred" with a tattoo. There have been no studies directly examining the patient perception of the communication skills of a doctor who has a face tattoo however this study has provided superficial insight into the perceptions of medical students and medical school staff on this matter. Whilst a few members of staff described no problem, it showed that other participants felt that a facial tattoo would be "distracting" or difficult to relate to.
Though a facial tattoo may not affect a medical student's or doctor's cognitive ability, it could add another dimension to the consultation. Street et al. (2009) hypothesised that good communication skills may lead to improved health outcomes, however they note that there are intrinsic and extrinsic contextual factors that may consequently deter outcomes. The researcher proposes that it is possible for a facial tattoo to be a contextual factor and because of current perceptions, it may not be suitable for a medical student or doctor to have a body modification of this nature.
Focusing on the balance between the professional identity and personal identity of a doctor or medical student, Cruess et al. (2015) stated that the formation of one's professional identity is a conceptually congruent process with that of their personal identity. Therefore, if a doctor or medical student is aware of the professional expectations of them institutionally, they may be able to shape their personal identity alongside that. By having a student or doctor reflect on the affiliation between social roles, their professional identity and individual competencies (Jarvis-Selinger et al., 2012), it could be hypothesised that if people are aware of the perceptions of patients and those explored within this study, they may consider the appropriateness of a tattoo whilst still maintaining their autonomy.
In contrast, some students and staff believed that it was not possible to consider your professional identity if you have chosen to have a tattoo at a younger age. It was discussed that it would be unfair to deny individuals entry to medical school if they had been tattooed before considering medicine as a viable career option. This study offers no conclusive answer, but importantly has highlighted that this an issue that merits consideration. Wohlrab et al. (2007) identified that certain personality traits still existed more commonly in tattooed individuals. A few students discussed certain behavioural traits that they associated with tattooed individuals. For example, creativity, outgoingness, but also rebellious, which is not classically described as being a personality trait of a medical student or doctor (Lievens et al., 2002;Powis, 2014). One characteristic identified by Wohlrab et al. (2007) was "sensation seeking" -the engagement with risky behaviours and hobbies. This study determined that students were aware of this trait within tattooed individuals, however in the medical context, where there is such a rigorous application and interview process that examines interpersonal skills as well as personality traits (Albanese et al., 2003), the researcher feels that such individuals would most likely be identified.
Recently, an understanding of the patient perception of tattooed healthcare providers has been sought (Westerfield et al., 2012;Johnson et al., 2015). These studies have shown that patients have reduced confidence and trust in healthcare providers who are tattooed, affirming the assumptions of the students and staff here. Whilst, the reduced level of confidence and trust does not mean the doctor is behaving unprofessionally, an effort should be made to study these perceptions to find out if doctors should practice with visible tattoos. Ultimately, if patients have reduced confidence in tattooed healthcare providers, are doctors and medical students with visible tattoos really dressing in the manner which the Scottish Government instructs?
"…dress in a professional manner which is likely to inspire public confidence…" (Scottish Government, 2010: p9) Both students and staff discussed the change in tattooing practice and how it is has evolved since previous generations. The comments raised underpin the concept of the 'tattoo renaissance', which highlights the cultural shift toward mainstream practice. What this does not provide information on, though, is whether these cultural shifts also apply to the healthcare environment.
Equivalent to changes in tattooing practice, participants from both cohorts expressed there had been changes in their own attitudes over time. Certain staff commented on how their opinion had changed because of contact with tattooed patients -their exposure to tattoos moulded their perception. These staff perceptions may be following the conclusions of Dickson et al. (2014), who put forth that those with tattooed friends or family members are less likely to stigmatise tattooed people. Whilst the staff members' patients were not all family members, it is important to review their background. Five of six staff interviewed work in general practice where there is longitudinal contact with the same patients. Therefore, caution should be taken when generalising these results as it is unclear if this is a fully representable sample of medical school staff based on all of them possessing clinical experience.

Limitations, Conclusions and Future Recommendations
The time constraints of this study must be recognised; those who participated volunteered to do so. Therefore, it could be surmised that those who volunteered had an active interest or a strong opinion on the researched topic, hence, yielding the possibility of an over-representation of strongly opinionated individuals in comparison to those who did not have such strong thinking.
Broadly speaking, the results generally suggested that medical students and medical school staff perceived tattoos similarly. All staff and students that offered an opinion agreed that certain tattoos were not appropriate for a medical student or doctor. Additionally, both cohorts largely agreed that there were locations for a tattoo less appropriate for a medical student or doctor, with the face being the subject of most contention. There were no major disparities between students and staff regarding tattoos. Several students communicated that they felt a tattoo would not affect an individual's professionalism at all whereas no staff members expressed this. Staff only held this view if all other elements in the medical 'situation' was standard.
The concept of a medical student's or doctor's professional identity versus their personal identity was acknowledged by both contingents. Further, both cohorts were represented in each opinion; a variety felt that individuals should be allowed full freedom of expression whereas others believed that certain tattoos would have to be mitigated. Nonetheless, no participant dismissed the notion of policy creation. Whilst a number of participants interpreted such actions as being complex, the consensus was favourable in terms of supplying clarity to tattoos in healthcare, a traditionally grey area.
After reviewing the literature, along with the findings from this study, the researcher proposes the following recommendations: It may be beneficial to determine patient perceptions of tattoos within a similar context to this study. Such I.
research has not been attempted in Scotland and it would be interesting to explore how these align with those suggested in the literature and by the participants of this study.
This study highlighted that negative perceptions towards tattoos still exist, specifically face and 'offensive' II.
tattoos. The GMC should become aware of these results and determine the appropriateness of such body modifications.
These recommendations were formed and based on the contemporary perceptions of tattoos within the University of Dundee medical school in the academic year 2016/2017. Just as attitudes towards tattoos have changed progressively, these recommendations could evolve, as well.

Take Home Messages
-Broadly speaking, the results generally suggested that medical students and medical school staff perceived tattoos similarly.
-Both cohorts perceived some locations for a tattoo to be less appropriate for a medical student or doctor, with the face being the subject of most contention. Additionally, all staff and students agreed that certain tattoo depictions would not be appropriate.
-In general, participants were in favour of policy creation and would like to provide clarity to a traditionally grey topic within healthcare.