The Human Beneath the Coat

This morning I was awoken by what can be generously described as Chinese water torture or, in layman’s terms, the cold wet snout of a dog. I arose feeding off the energy gradient of his excitement to my sleepiness. I fetched my hat to cover my bedhead which my stylist of a pillow seems to master into the Don King every night. We stroll around the block, the thick, muggy summer morning so characteristic of Southwestern Virginia clings to my t-shirt. I say hello to passing neighbors, most of them just familiar faces on the same morning routine. It is pleasant, though, to walk anonymously.

My days are currently filled with study, after a year in the clinic I am once again in the seemingly endless cycle of boards preparation. A combination of finessing your practical knowledge and the hoops of incessantly memorizing bytes of data that as the years advance will be useful either at a physician bar trivia night or not at all.

For the time my coat hangs in the closet with my stethoscope draped over it, waiting for me to dawn it again for my last year of medical school. For now, it is tossed this way and that as I search for a shirt or jacket in it’s vicinity. But it waits patiently. Two years ago, I wrote a piece entitled “Don’t Wear the White Coat; It scares the kids.” In it I explored some of my thoughts on the coat as a barrier to care.

Though I still have many of those same sentiments, there is much more grey area now. The symbolism of the coat is undeniably historic, something of which I am proud. It is also, however, a barrier, one that works both ways. A shield for me, and perhaps a shield for the world against me.

My first day of clerkships, as our rotations are sometimes called, remains as vivid and etched in my memory as can be. The fear and panic sumperimposed on excitement. The instantaneous self doubt and urge to abandon this seemingly wayward vessel of a career in which I had found myself. I dawned my jacket, cinched my bowtie into the tightest knot, stuffed several pens in my pocket, and threw my stethoscope over my shoulder. Yet, it was still a costume. I am not a doctor; I just play one on TV! I felt small, as if a child dawning his father’s suit jacket. But there I found myself. Standing in the fluorescent lit halls, the sun yet to peak over those West Virginia moutnains. I felt like Vonnegut’s Billy Pilgrim, torn out of my own reality, and dropped into another. My only armor in this new world was my coat. In which I could stuff papers with spells (or patient data), potions for energy (my Cliff Bar), and even my mace (ok, it was just a pen light).

As directed at 6:30am, I went and saw my first patient. I had their info, their history, and daily labs, yet I still felt helpless. So I nervously conducted an interview and exam, and as I was washing my hands to leave the patient said to me, “Thanks, doc.”

My heart sank. For some, this may have been an extremely gratifying moment. This is so much for which we had worked. Not for the recognition, but to truly and genuinely make a difference in people’s lives. In those agonizingly long few minutes, though, the weight of my inexperience, my own struggles, and all of which I had (and still have) yet to learn crushed me. In that asphyxiating moment of panic and doubt, my coat protected me.

For so much of your time in the hospital, you wear that coat. It’s length denoting your incomplete training, but it’s starched professional appearance bestowing upon you a humble role in patient care. The coat affords you some privacy and separation. In the hospital with a coat, you are student doctor. You act accordingly in your role, you learn, you engage in a professional manner, and you build who you are as a physician in training. Patients and staff associate you with your role. You build a new aspect to your personality, and add style points to your repetoire of interaction and care. The coat becomes a switch. When it’s on, you’re on. When I leave the hospital and slip my jacket around the passenger seat, I am off. I am not Student Dr. Truett. I am Cullen.

Now, I know there are those who are going to rebut that I have accepted a career and a calling, one in which I never turn off. To some extent, those people are correct. Part of being a healer is recognizing the needs of others before your own. That being said, the other part of healing is recognizing your humanity and fallibility, so that you may recognize the same in others. Even more so, one must acknowledge the duality of their character.

The person I am as a physician, is a distillation of me. It is me. It is a more careful me, a more precise me, at times more guarded and driven by reason. In many ways it is a more confident me. My doctor self shares my, hopefully apparent, warmth and jovial nature with staff and patients alike. I care. I really do care. As much as we have to guard ourselves and balance our emotional investment, I really do give a damn. We all do.

And it is this distillation that makes doctors such enigmatic beings sometimes. I often hear people speak of their physicians with great affection and respect, but also some puzzlement, like they cannot quite peg down who we are. Which is kind of the point of our efforts. When we slip into our white coats, we put on that thin but potent barrier that allows us to get close to you, to heal you and comfort you, but keep a miniscule but significant distance between us.

As much as this is the point of our efforts, in some ways it serves to our detriment. As physicians we face astounding pressures on all fronts. We are expected to be timely, by both our patients and by the industry. Administrations and insurance companies expect patients to be seen every 15 minutes, because profit margins (another whole topic, which I cannot even begin to address today) and the business (see previous parentheses) drive such a standard. Efficiency in overdrive is the norm, and yet we are also expected to make no errors. Patients too expect timeliness. No one wants to wait in the office for hours, though they certainly do. Even I too often become impatient with waiting, even though I know my visit is a brief one. Yet, we also expect our physicians to make the world stop for us and treat us like old friends, never rushed and always thorough. The physician shouldn’t be distracted with family matters or personal problems. For those moments we are the the center of their world. We want it all, because in so many ways our society allows us to have it all. Yet the unique construction and situation of each individual, does not permit such expediency.

We try. We strive for the best. But we are human. Beneath those white coats we are dads, moms, siblings, boyfriends, girlfriends, straight, gay, happy, depressed, etc. As humans we beg for other humans to heal us. We yearn for that touch and comfort, complaining of how technologically driven and cold medicine has become. Yet, we continue to demand superhuman perfection, and an industry has capitalized on such desires, overthrowing the balance of humanity that we as physicians are at least taught to try and maintain. We demand superhuman feats of our most dedicated and loyal servants, a third of whom recently reported desiring to leave the field of medicine before retirement.

When I am out like today, in t-shirt and shorts sipping coffee, my neighbors see just another guy. My friends know my dorky, and at times darkly irreverant sense of humor. I’m the guy at the microbrewery that likes to talk politics or culture. I am the guy on the plane with a New Yorker magazine. I am the runner on the bridge, and the driver you passed, middle finger extended for going the speed limit (Jokes on you. The trooper is behind that bush). I am a son, a boyfriend, and a free spirit. I am the man behind the coat.

Pay no attention to that man, or perhaps you should. Maybe we need to update our social contract. Maybe we need to integrate our idea of medicine into the health and welfare of our communties once again. Out of deference to good care, and also our own sanity we have formed these multifaceted barriers between us and the rest of society. It’s not good nor bad, black nor white. What’s the best way forward? I do not have the answer. I only know the balance, the chess match of being guarded and being humanistic is one of the noblest and greatest struggles of medicine, one at which we often fail.

The coat is my curtain, and I am the wizard. Or perhaps, I am just a small man in a big world, trying to make a difference as I hope some many of us are.