THE BOOK AND THE COAT
Some gifts are really warnings. In our first month of medical school, we received two such gifts when the University of North Carolina, like medical schools around the world, held its white coat ceremony.
If dissection was our private induction to medicine, the ceremony was our public one. The first took place in a windowless lab at the medical school, the second in an august auditorium on the main quad of the campus. It was held on a weekend. Parents came. Pictures were taken. Punch was served. Parting gifts were passed out: a book and a coat, white, as promised.
The coat was an emblem of our noble calling. It was placed over our shoulders, stiff and untailored, still bearing the creases from its packaging. We knew that as we tended to people who were bleeding or vomiting or otherwise making a mess on us, the coat would receive the stains of our experiences. We also knew that we were expected, somehow, to preserve its whiteness. When the coat got dirty, we were to clean it. When we could no longer bleach and starch it into a semblance of its original state, we were to replace it. As a gift, the white coat implicitly warned us to maintain a distance from the ill. The coat was to mark us out from other people.
The book, On Doctoring, was an anthology of texts about practicing medicine. Every year, each American medical student receives a copy. It is, in all likelihood, the only book all American medical students own. It includes essays, poems, and stories—a miscellany of love letters about being a physician.
The book and the coat: ritual objects, one might think, handed down to medical students since the time of Hippocrates. In fact, the book, the coat, and the ritual at which we received them are all recent inventions of the humanism-in-medicine movement, whose aim is to reform medicine by encouraging students and physicians to take a more humanistic approach to medicine.
The association of the white coat with physicians can be traced back to the era of William Osler. In his own clinical practice, Osler favored a full suit, but he wore a white apron when dissecting, and he would have understood the impulse behind the white coat, which makes physicians resemble laboratory scientists. The association was intentional: when Osler began his career, physicians were only one group among many types of healers jockeying for public approval. Many physicians were poorly trained patent medicine peddlers competing for patients with local homeopaths, hypnotists, and hydrotherapists. Osler helped physicians distinguish themselves from these other healers by teaching them to present themselves as scientists, who, at the time, often wore tan lab coats to protect their clothes during experiments. Lab coats were practical and without pretense. In the late nineteenth century, many surgeons adopted the light-colored lab coats in the operating theater to signify their commitment to the new, antiseptic techniques. These surgeons were clean; their coats were the proof.
The physicians’ lab coats also made their wearers look like priestly counterparts of the nuns who staffed many nineteenth-century hospitals. Like a priest’s robes, the white lab coat suggested the purity and power of its wearer. By the time Osler died, the white lab coat was widely associated with physicians. They were scientists. They were professionals, deserving their authority and society’s respect.1
By the time of my training, the white coat was so essential to the physician’s public presentation that we acquired two of them in the first month of medical school, one at the ceremony and one purchased, unceremoniously, from the medical school bookstore. Practically, we preferred the second coat, because we wore it to protect our clothes while we dissected cadavers. These were work coats that no patient would ever see, so they could have been any color, and yet none of my classmates purchased anything other than a white coat. Politically, we wanted a white coat because it signified our status as medical students. In a tan or blue coat we might have been confused with the janitorial staff. We were training to be physicians, so we selected white coats for the privilege they conveyed. We kept these coats on the top floor of the medical school in closets outside the dissecting rooms, where they soaked up the potent chemicals. By the semester’s end, they were so damp that they clung to us like primer on fresh boards.
The honorary white coat was startlingly clean and emitted the sugared smell of perchloroethylene and other dry-cleaning solvents. It was cut short at the waist, to indicate our place in the medical hierarchy. Senior physicians wore long cotton coats with braided buttons. Resident physicians wore long polyester-cotton-blend coats with translucent buttons, their names embroidered over the heart. Intern physicians also wore long poly-cotton-blend coats, but with the name of the hospital stitched where they hoped their own name would someday reside. Our short coats had neither name nor logo.
At our white coat ceremony, Dr. Stewart Rogers, a respected internist on the faculty, addressed us. He described the white coat as a symbol representing the “Mantle of Hippocrates.” So far, so traditional: we were going to invoke the great physicians of old and claim a bright line connecting us back to them. Then Dr. Rogers asked whether we would wear the coat as apron or as armor.
Armor would protect us, and Dr. Rogers admitted that we would need protecting. The white coat, he told us, would help us “stay clean and calm—for the next patient, for our families, for our peace of mind.” The coat would even help us maintain enough professional distance to avoid burnout. The coat, he hoped, could protect us while preserving our empathy.
But he cautioned that we would eventually need that empathy, and he clarified: “The white coat is an apron, not a suit of armor, and you’ll appreciate the design—it opens over your heart.” The coat opened over our hearts to allow our empathetic engagement with patients. He observed that a white coat would show stains, and warned us, “Never forget that the worst stains spill from your own character: from neglect, impatience, or greed.” He noted that the coat could also serve as a satchel for the tools we carried and as a badge of our clinical privilege. He advised us to feel gratitude to the citizens of our state, who generously subsidized our education. He urged us to appreciate the “creativity, conscience, humor, kindness, generosity, or courage” of our patients. Finally, he concluded, “There is also a warning, in fine print, that some of you may forget to read: ‘This coat will fit better and last longer if you do not wear it all the time.’ Remarkable as it is, your white coat will not exhaust all your talents or meet all your needs. So hang it up sometimes, even during medical school.”2
It was a bracing speech. Dr. Rogers had delivered real advice. Be grateful for the coat. Be worthy of the coat. Be afraid of the coat. He is the first physician I remember sounding a warning about what medicine could do to its practitioners. And I was struck by how personal his warning was. He did not talk, like many of the people I knew, about disliking his job or his boss. He talked about fearing what being a physician did to him and what it could do to us.
His words seemed to dissipate quickly, however: We were here to celebrate. Who was this old man issuing warnings? We were wearing party clothes. Why was he hanging crepe? The remaining speakers offered aspirational exhortations. They called us to the elevated stage, enrobed us in white coats, and welcomed us to the profession. We recited the Hippocratic Oath. The audience cheered. The auditorium cleared, but Dr. Roger’s warning stayed with me.
Walking home, I did not feel as though I belonged to the profession. I still identified with the patients, not the physicians. Although I left the ceremony with a truncated version of an attending physician’s coat, I felt like a fraud. I was not a junior physician, half as good as a practicing physician, but a mere student. If I dropped out of med school during the next month—and a couple of my classmates did—I could tell people only that I used to be in med school, not that I used to be a physician. If I wore the anonymous white coat outside the hospital, I would look much more like a busboy than a physician. But when I wore the coat in the hospital or clinic, I received an undeserved share of the physician’s privilege. A week later, when I told Gloria’s son that she was dead, the coat added professional privilege to the list of privileges—those of race and class—that divided us.
Years later, certain objects would make me feel like a real physician—a pager, a prescription pad, my first student loan bill—but not my anonymous white coat. Part of the reason for this was because the day’s ritual seemed forced, like a concocted religious service. Most of the audience were dressed in their Sunday best, and we sat together in a sanctuary, listening to inspiring words, but the ecstatic moment never arrived. I heard the warning issued by Dr. Rogers in his remarkable homily, but the ritual never provided the release I expected. The ritual felt like a stage show. As, in fact, it was.
. . .
The white coat ceremony dates only to 1993, when it was first performed at Columbia University through the sponsorship of the Arnold P. Gold Foundation. Named after its founder, a renowned child neurologist on the Columbia faculty, the Gold Foundation sponsors research, awards grants, and introduces initiatives such as the white coat ceremony to promote humanism in the medical profession.
Gold and his wife, the generous sponsors of these initiatives, are seeking to reclaim what they believe has been lost in medical education and practice. When Gold compared his own training to that of a contemporary medical student, he saw it as both more demanding and more humane. When he described apprenticing himself to a Dr. Smith, for example, he wrote, “I slept, ate, and stayed at the side of my patients. Dr. Smith’s behavior was my curricula; her values informed my own. There were none of the competing values and messages that are prevalent today. Residents and students did what their attendings modeled. Altruism was the rule, and meeting the needs of the patients, whatever the personal cost, was the norm.”3 He regretted that in contemporary medicine this apprenticeship model and its values have been eroded. He wished to restore the synthesis, personified by Osler, of rigorous science and empathetic humanism in medical education and practice.
Gold wrote that he developed the white coat ceremony at Columbia “to welcome new students into the profession and introduce them to their responsibilities toward patients.”4 These responsibilities chiefly include virtues like compassion and humility. As Gold described it, each ceremony has a common structure. Students are welcomed to the profession of medicine, they recite an oath of their choosing, are cloaked in white coats, listen to an inspiring address by a leading physician, and then celebrate at a reception. The Gold Foundation actively supports the adoption of the ceremony, offering grants to pay for a school’s first ceremony if the school will commit to future ones. The ceremony has been adopted by the majority of American medical schools, as well as by medical schools in countries as far-flung as Australia, Germany, Pakistan, and the United Kingdom; it has also been adapted for pharmacy and physician-assistant schools. The white coat ceremony has become a ritualized induction of medical students into the profession, but it is also an effort to renew the practice of medicine through Osler-style humanism. The foundation is always expanding its scope: it operates the Gold Humanism Honor Society to recognize medical students, trainees, and physicians who exhibit clinical excellence and humanistic care; it recently announced that it planned to design a parallel ceremony for resident physicians as they begin their training; and it sponsors professorships for faculty members engaged in encouraging humanism in medicine. The foundation’s goal is for every physician to be a humane physician. I admire the Golds, their foundation, and their earnest work, but the ceremony unsettled me. Dr. Rogers’s warning—that it was the defects in our character that would most stain our white coats—seemed a more fitting induction than the ceremony itself.
I am not alone in feeling discomfited by the ceremony. Some observers fear that the ritual reinforces the hierarchies of medicine.5 Unlike nursing students, who wear surgical scrubs during training, medical students wear dress clothes underneath their white coats, marking themselves as white-collar professionals. As students in our short coats, we were on the bottom rung, but we were on the professional ladder, and the ceremony made me want to ascend the ladder, to be worthy of the long white coat. The ceremony encouraged our solidarity with the profession, not with our future patients, and signaled that we were members of the medical profession, with a measure of its associated responsibilities, to be sure, but also with a measure of its privileges. As long as I was wearing the white coat, no one would ask why a medical student a month into his training was watching Gloria die and then telling her son about it afterward.
The ceremony also communicated to us that professionalism and humanism were equivalent. The professional student physician was the humane student physician. In an essay explaining the ceremony, Gold wrote that “humanism is the central aspect of professionalism,” as if humanism were a part of professionalism, rather than a separate but related concept.6 In Gold’s writings and the work of his foundation, the words humanism and professionalism are often used synonymously, as they were, to my surprise, at the ceremony. I had always understood humanism to mean being oriented toward rationally addressing the needs and well-being of a person, and in the context of medicine, it seemed to me that humanism meant putting the needs of the ill person, or patient, first. I took professionalism to mean possessing or displaying the skill and character of a member of a particular profession. In medicine, it seemed as though professionalism meant aspiring to be like Osler, a skilled and respected physician. If the foundation really wanted to emphasize humanism, why not give medical students a gift that reminded them of their solidarity with the ill rather than their identification with physicians? Or, since our short white coats resembled those of busboys, why not tell us that we were the servants of our patients? Why not have us pledge something like the Oath of Maimonides, in which an aspiring physician promises to “never see anything in the patient but a fellow creature in pain?”7 Or why not omit oaths altogether? A recent survey found that only one in four practicing physicians describes medical school oaths as influencing his or her current practice.8 Our ceremony was well-intentioned, but it collapsed the differences between serving the needs of patients and fulfilling the responsibilities of the profession. Dr. Rogers discussed the white coat’s multiplicity of uses—armor, apron, satchel, and badge—and warned us about the potential cost of wearing it. But the ceremony insisted it had only one use: it was “the mantle of our profession.” In celebrating the coat as an ancient symbol, it obscured its history as a modern invention, part of the shift toward conceiving physicians as scientists.
. . .
Every religious community needs sacred texts. At our white coat ceremony, the dean of the medical school passed out copies of the On Doctoring anthology as ours. We carried them home in our white coats, although they were quickly replaced in our pockets by practical, instrumental texts with miniscule type and more diagrams and tables than paragraphs. In an era before smartphones, most medical students carried a trio of pocket books—the Maxwell Quick Medical Reference Guide, the Tarascon Pocket Pharmacopeia, and the Sanford Guide to Antimicrobial Therapy. There was barely a metaphor among them, let alone a poem or story. So the anthology seemed like a real gift, bound in hardcover, and protected with a dust jacket. On the dust jacket was a reproduction of Norman Rockwell’s 1958 Saturday Evening Post painting “Before the Shot,” in which a white-haired, white-coated physician is preparing to administer an injection to a young boy. The physician’s skin is also white, as was that of most of the writers featured inside the book—certifiably great, capital A authors such as Auden, Chekhov, and Hemingway.
The era depicted by the Rockwell painting represents the pinnacle of physician authority in America, and the whole book had a wistful quality to it. Back then, it suggested, physicians were well compensated, well respected, and well obeyed. The book’s contents were engaging but reverential, as if medical training and practice were comparable to a series of Rockwell scenes in which the physician was a central character. The texts did not reflect the usually disjointed, occasionally hilarious, and often tragic experience of medical training and practice. When the dissenting voices in the anthology criticized physicians, it was to describe someone who did not live up to the standards of the profession, not to question the enterprise of contemporary medicine. Most of the excerpts contained an easily extractable moral lesson.
The texts seemed to have been selected and excerpted in order to make Osler happy, even if, as far as I can tell, none of them came from Osler’s reading list. Osler liked writers from an earlier canon. He loved Cervantes, Emerson, Epictetus, Montaigne, and Plutarch.9 None of these authors appeared in On Doctoring. And there were other differences. Osler recommended a small library of books to his students, often the entire corpus of a writer. We received a single book. Although Osler loved books about medicine, his reading list covered a broad range of topics. We received only texts about physicians. Still, there were continuities between Osler’s reading list and the anthology. Most important was the humanistic tone of the texts. In addition, readers were encouraged to identify with physicians rather than patients. The experiences of the authors, many of them physicians themselves, provided a further link. Osler had called the graduating army surgeons out of their own communities and into the community of physicians, and the anthology was implicitly doing the same. Even though the authors and the texts had changed from Osler’s day, this book was, like the white coat, an updated version of Osler’s reform. Physicians were to be scientists and humanists.
Like the white coat, the anthology was paid for by a foundation interested in renewing the practice of medicine in the manner personified by Osler. In 1989, the Robert Wood Johnson Foundation created it with a stated goal of altering the tone of medical education and practice, and has subsequently paid for each American medical student to receive a copy.
Although the effect of the anthology on contemporary practice would be hard to assess, it is difficult to overstate the role that the Robert Wood Johnson Foundation plays in contemporary medicine. Through its Clinical Scholars Program, the foundation has trained two generations of leaders in academic medicine. The foundation is the largest American philanthropic institution dedicated specifically to healthcare, and it distributes around $400 million in grants annually. In this context, the On Doctoring anthology is a small but tangible symbol of the foundation’s philanthropic portfolio and its efforts to alter health and healthcare.
For me, it would be hard to say that the anthology altered my life. I read it once but found it relentlessly uplifting; a few months later, I included it in a box of books that I took to the used bookstore. They offered me only a dollar in store credit for the anthology. When I asked why, they pointed to a shelf of five other copies and said, “Med students drop them off every year.” I traded the anthology for one of the books excerpted in it, Abraham Verghese’s memoir My Own Country.
Recently I started thinking about the anthology again and wondered why a large philanthropic organization would take pains to fund and distribute it. In one of the Robert Wood Johnson Foundation’s published reports, the anthology’s editors, Richard C. Reynolds and John Stone, described the book’s genesis. As a high school student, Reynolds had read Sinclair Lewis’s Arrowsmith and A. J. Cronin’s The Citadel, early-twentieth-century novels with idealistic physician protagonists directly inspired by the Oslerian reform of medicine. Reynolds wrote that the novels sparked his interest in medicine. When he joined the foundation staff in 1987, he also recalled an initiative by the pharmaceutical company Eli Lilly that from 1923 to 1953 paid for every graduating American medical student to receive a copy of Aequanimitas, a collection of Osler’s speeches. Reynolds remembered this as a happier moment, when pharmaceutical companies passed out books rather than advertisements to physicians. He recalled asking representatives of the industry earlier in his career if they might distribute classic medical texts, including Beaumont’s account of dissecting Alexis St-Martin—a reference I found telling. The goal of the anthologists was truly Oslerian.10 They, like Osler, wanted physicians to read Beaumont’s writings on gastric physiology, implicitly encouraging students to identify with other physicians rather than with patients like St-Martin. The anthology was implicitly teaching medical students how to listen to the stories of the ill. The anthologist wanted me to listen to those stories so well that I could, in my own practice of medicine, craft each patient encounter as confidently as the authors in the anthology. The aim was to keep idealistic medical students from becoming alienated physicians by teaching them to attend closely to their patients by reading, and even writing, empathetic literature. The anthologists wanted me to be the expert reader, or maybe even the author, of the people I would meet as patients. That seemed to me like a good way to promote professionalism, but if we want to encourage medical students to embrace humanism, perhaps they should instead be asked to read a patient’s account of being ill and receiving medical care—the story told from St-Martin’s perspective rather than Beaumont’s.
In joining professionalism with humanism, the anthologists continued the work of Osler, who believed medical humanism to be as essential to reforming medicine as autopsies. He pressed a standard reading list upon his students and trainees. He quoted great literature in his talks—in his address “The Army Surgeon,” in which he encouraged the graduating physicians to see much and to see wisely, Osler managed to reference Thomas Browne, Thomas Carlyle, William Shakespeare, Laurence Sterne, and Hebrew Scripture. Osler understood himself within a tradition of Anglo-Saxon writers and spoke to his trainees as if they belonged to the same tradition. So when Osler told the graduating army surgeons—“Your praise shall still find room. Even in the eyes of all posterity”—he was using a Shakespearean love sonnet to laud his audience.11 Medicine was a humane science that was ever progressing, its practitioners were heroic, and literature from great white English writers offered the proof. In addresses like the “The Army Surgeon,” Osler, like the On Doctoring anthology after him, obscured the particularities and the histories of the texts he cited in order to narrate stories of the humane physician as a constant throughout Western history.
. . .
The conflicting messages about professionalism and humanism in the white coat ritual established a pattern for the rest of medical school. Moments of hard-earned wisdom were obscured by the constancy of professional formation. Our formal education was often truly humanistic. Our medical school employed a department of scholars in social medicine who introduced students to the economics, ethics, and history of medicine and scores of learned clinicians who impressed upon us the need to be humane in our care of the ill.
These clinicians taught me what I did not know when I saw Gloria die: how to speak with and examine patients. Every Wednesday afternoon, we had formal lessons to learn how to talk like a physician. My teacher was a family physician named Donald Spencer. When you meet a patient, he said, “You introduce yourself. You ask their name. You ask how you can help them.” Dr. Spencer made it seem natural. He moved about an exam room with poise and purpose. His face defaulted to a smile. When he spoke, his voice was soft but certain. Patients were reassured. Students were inspired. He spoke of the responsibilities we had to our patients.
I heard him.
I admired him.
Yet on my clinical rotations I learned something different—how to see people as compendiums of parts and money. When residents and attendings quizzed me about a patient, they never asked about his or her strengths or passions; they wanted to know about the physical exam findings, lab values, and pathophysiology. When no one asks about something, you learn that it is not important. Medical educators call these kinds of formative learning experiences the “hidden curriculum” or the “null curriculum,” which contains the implicit messages that medical students receive in training through what is not discussed. The hidden and null curricula undo the work of the Dr. Spencers of the world.
As I came to the realization that Osler’s grand synthesis, the first contemporary proposal to reform medicine, confused professionalism and humanism, I began to remember many examples from my training. When I was a third-year medical student, I received a community service award for volunteering at the medical school’s free community clinic, where we provided check-ups, screenings, and referrals for people who could not afford medical care. For me, the work was a reminder that many people cannot afford healthcare and a chance to offer a bit of service. The award was a hardbound copy of the same anatomy atlas we had used when dissecting cadavers as first-year students. Today this prize copy of the atlas sits on my office shelf—its pages clean and spine intact. It is a sanitized version of the book I once used in the cadaver lab, with pages oil-stained by human fat and paperback binding broken in thirteen places. The prize copy seems to represent a sanitized version of my training, something that obscures the messy history of medical training and practice. Although I appreciate the award, I prefer objects whose history is more apparent and acknowledged.
I still own a white coat. I am an attending physician now, so it is a long white coat. It is made of cotton, and its buttons are braided. Dr. Rogers observed that our white coats opened over our hearts to allow us to engage our patients empathetically. That is a statement of humanism, but on the coat I own, my name and title are embroidered over my heart. My professional identity is announced over the metaphorical home of my empathy. On my coat, as often occurs in medical practice, humanism loses out to professionalism.
Still, I remembered Dr. Rogers’s warning, and I eventually heeded it. As a medical student and resident, I wore a white coat constantly, but I no longer wear it very often. It resides on a hanger in my office, unstained but dusty.
I have not, however, stopped searching books for thoughts on how best to be a physician, so I recently read the book passed out to a previous generation of physicians, Osler’s Aequanimitas. The title refers to the professional characteristic of, as Osler writes, maintaining “a calm equanimity” in the face of any situation. “The Army Surgeon” is included in Aequanimitas. So is an address from 1901, “Books and Men,” in which Osler remarked, “It is hard for me to speak of the value of libraries in terms which would not seem exaggerated. Books have been my delight these thirty years, and from them I have received incalculable benefits. To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”12 I was struck by his metaphor: the physician as ship’s captain, setting out on a sea of illness, with books as his charts and guide. I wondered whether it might point me to a version of humanism in medicine that did not collapse into mere professionalism.
I decided to reread some of the books that had guided me in medical training, beginning with the book for which I traded in On Doctoring, Abraham Verghese’s My Own Country. I remembered the book’s humanism and wanted to see whether it could still inspire me on my search as I set out on the seas Osler had charted for us.