Patient Perceptions Across a Fixed Sequence of Physician Attire and Surgical-Context Images in Urology: An Image-Based Cross-Sectional Survey.

BACKGROUND: Physician attire is associated with patient trust and confidence, yet it has rarely been examined in urology or in the surgical context in which the physician is seen. AIM: To examine how physician attire and the displayed surgical context are associated with patients' initial perceptions of urologists using standardized, artificial intelligence (AI)-generated images. STUDY DESIGN: Cross-sectional study. METHODS: A total of 220 adult urological patients rated 10 standardized AI-generated physician images, presented in the same fixed order, using 11 5-point Likert items and one binary acceptance item. Five images varied by attire (casual, business suit, suit with a white coat, scrubs, and scrubs with a white coat), and five varied by surgical context (neutral, open, endourological, laparoscopic, and robotic). Images were matched to each participant's stated physician-gender preference; the male-image stream (n = 189) formed the primary analysis, and the female-image stream (n = 31) formed a secondary analysis. Within-subject comparisons used the Friedman test with Bonferroni adjustment across outcomes, Page's trend test for the ordered attire hypothesis, and Wilcoxon signed-rank tests. Treatment acceptance was modeled using generalized estimating equations (GEEs) with an exchangeable working correlation. RESULTS: Ratings varied across the fixed, ordered attire sequence for every perception item (Friedman tests, all Bonferroni-adjusted p < 0.001); Page's trend tests for the two primary outcomes were also significant (both Bonferroni-adjusted p < 0.001). Because the attire category was perfectly confounded with presentation position, this pattern cannot be attributed to attire independently of order. For male images, mean trust increased from 2.98 ± 1.34 (casual clothing) to 4.26 ± 0.81 (scrubs with a white coat), and choice likelihood increased from 3.07 ± 1.37 to 4.29 ± 0.84; observed binary treatment acceptance increased from 56.1% to 97.4%. In the adjusted GEE model, acceptance was higher at position 5 (scrubs with a white coat) than at position 1 (casual clothing) [odds ratio, 39.1; 95% confidence interval (CI), 13.1-116.7; adjusted risk difference, +40.3 percentage points; 95% CI, 32.6-48.0]. By contrast, only leadership and attractiveness remained significant among the surgical context comparisons after adjustment, and all context effect sizes were small (Kendall's W ≤ 0.03). Because the context images also differed in several unintended visual respects beyond the operative setting, this comparison is restricted to the specific images shown. CONCLUSION: In this standardized, image-based survey, ratings varied systematically across the fixed, ordered image sequence, with the largest and most consistent differences appearing across the images intended to vary in physician attire. Because the attire category was perfectly confounded with presentation position, this association cannot be attributed to attire alone. Associations with the displayed surgical context were small under the conditions tested and are further limited by unintended differences among those images beyond the operative setting.