Burn The White Coat

by Rocco Monto, MD

Symbols are powerful things. They can unite us and they can divide us. Most of the time they do both. Few symbols over the past one hundred years have been as recognizable as the doctors' white coat. Initially adopted during the late 19th century at Massachusetts General Hospital, short-sleeved lab coats were first worn by surgeons to introduce the concept of sterility and emphasize science in a field previously considered dark and dangerous by the public. As most medical care transitioned from home to hospital, the white coat quickly supplanted the black bag as the recognized symbol of physicians across the country.

Gradually, as medical knowledge advanced along with post-war technology, the power of the physician as a healer grew and began treating patients with a benign paternalism marked by detached concern. (1) The white coat came to represent hope and healing to a largely uneducated population. But just as the powerful symbolism of the white coat peaked in the 1960s, new social forces emerged that began to undermine it. The real power of the white coat was the guild of knowledge it represented. Consumerism and populist movements gained a foothold in the US in the 1970s and the public began to question the motives of its government, religions, and other institutions. The iconic image of the white coat clad physician lounging over a cocktail at a country club mixer was an easy target during this time of social upheaval. There was a reason Marcus Welby, MD, was canceled in by ABC in 1976. The world was changing.

The democratization of information unleashed by the internet in the 1980s finally reversed the long asymmetric relationship between doctor and patient. The information gap was erased with the click of a mouse. A new dynamic of parity was established and doctors struggled as they found themselves devalued in society. The 1990s were marked by “brain drain” of the best and the brightest as medical school application rates declined and business school rates soared. Medicine, like many other organizations, reacted to growing public criticism by intensifying their symbolic identification. In a social phenomenon known as “threat rigidity”, physicians circled the wagons and clung to their symbolic shields. (2) The honor code of the Hippocratic Oath was no longer sufficient to distinguish doctors. Enter the “white coat ceremony.”

The first white coat ceremony appeared in Columbia University in 1993 and has since been adopted by most US medical schools is a ritual in which new medical students are presented white coats and discuss their meaning. (3) But even as medicine tried to reestablish the positive symbolism of the white coat it was quickly devalued. Everybody started wearing white coats and having their own white coat ceremonies. Osteopaths, chiropractors, audiologists, nurse practitioners, physician assistants, lab technicians, physical therapists, pharmacists, dentists, radiology techs, and veterinarians now all wear coats. Massachusetts General Hospital alone buys 9,000 white coats every year.

Worse than the failure of the white coat to elevate our profession is the way it has separated us from our patients. Decades of social research have proven that differentiating groups decreases their empathy and compassion for one another. (4) Finding common ground seems to lower stress levels and improve empathy. Increased empathy and identification between doctor and patient has been shown to lead to better clinical results, fewer medical complications, higher patient satisfaction levels, and decreased malpractice suits. (5) Many pediatricians and psychiatrists abandoned their white coats years ago to ease office stress and alienation.

Symbols as strong as the medicine’s white coat can echo and resonate long after they have lost their social relevance. Citing studies demonstrating high levels of antibiotic-resistant bacterial clothing contamination, the UK banned white lab coats in their hospitals in 2007, instead of pursuing a “bare below the elbow” policy. This elicited protests from some physicians who felt they were being controlled and herded. In 2014, a US-based study recommended voluntary adoption of a similar “bare below the elbow” policy in American hospitals. (6)

While I disagree with Donald M. Berwick, MD, former head of the CMS, on many issues, he was spot on in this elegant address at his daughter’s commencement from Yale University School of Medicine in 2010:

“You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity- of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care — in the sacred presence of people just like you — when you take off that white coat, and tower not over them, but join those you serve, you become a healer in the world of fear and fragmentation, an aching world…that has never needed healing more.” (7)

Do patients care about the white coat controversy? New research conducted after the advent of the UK’s white coat ban concludes that the majority don’t. (6, 8) Patients want their docs to be smart, clean, confident, and compassionate. They want us to help them heal. Its time to take the white coats off and burn them. We don’t need them anymore.

REFERENCES

1. Halpern J: From Detached Concern to Empathy. 2001, Oxford University Press.
2. Rafaeli A, Pratt MG: Artifacts and Organizations: Beyond Mere Symbolism. 2013, Psychology Press.
3. Huber SJ: The white coat ceremony: a contemporary medical ritual. J Med Ethics, 2003; 29: 364–366.
4. Goleman DJ: Social Intelligence: The New Science of Human Relationships. 2006, Bantam,
5. Reiss H, Kelley JM, Bailey RW, Dunn EJ, Phillips M: Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen Int Med, 2012; 27(10): 1280–1286.
6. Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price S, Murthy R, Pamore T, Rupp MF, White J: Healthcare personnel attire in non-operative-room settings. Inf Con Hosp Epidem, 2014; 35(2): 107–121.
7. http://www.northeastern.edu/prehealth/wp-content/uploads/BerwickYaleMedSchoolGradAddress5_10.pdf
8. Collins A, Connaughton J, Hill A, Ridgway PF: Bare below the elbows: a comparative study of a tertiary and district general hospital. Ir Med J, 2013; 106(9): 272–27.