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White Coat, Black Book

At the start of medical school, many students participate in the “White Coat Ceremony.” Before peers, faculty, and family, they recite a modern version of the Hippocratic Oath (or other affirmations like the Geneva Declaration) and don the short white jacket they’ll wear during the four years of school. Although they begin seeing patients only in the third year, part of the ceremony’s intention is to convey that care for patients begins, in a sense, on this first day. When they earn their M.D., they are entitled to the knee-length version.

The white coat ceremony was conceived in the 1990s and popularized by the Arnold P. Gold Foundation. Doctors didn’t even wear white until the late 1800s: black was the standard attire. Like clergy at the pulpit (or the sickbed), physicians in black conveyed the gravitas of a medical encounter, perhaps signaling the meeting’s true nature: since medicine had little to offer, a visit with the doctor often portended death rather than healing.

Along with the oaths and speeches, the mass of bright white cotton at the contemporary ceremony reflects the novitiate doctor’s profound responsibility to patient and to society. In that sense, gravitas endures, despite the change in couture. In addition, the modern ceremony may have been designed to get students out of their blue jeans and baseball caps, to assume a somewhat more sober demeanor and give a nod to earlier centuries.

The switch to white near the turn of the 20th century coincided with the advent of hygiene practices in medicine, a pragmatic choice (one could bleach a white jacket) but perhaps a metaphor for a modern, “clean,” science-based practice. No longer would a blood and guts smeared black coat mark the experienced physician who was — despite access to some effective treatments — more like a benediction-bestowing priest than a scientist-practitioner. Innovations like antibiotics probably sealed the deal with white in the 20th century. Cutting edge practice entailed a pristine look, and no coincidence — white symbolizes purity. The starched white coat may have signaled to patients that their doctors’ actions were scientific and dispassionate.

However, the switch from black to white did not mean complete abandonment of a role akin to a person-of-the-cloth. In contemporary medicine, donning the white coat means a student will soon enter medical education’s rite of passage: clinical rotations, a vestibule to the rarified club of physicians. But these rites are also steps toward ordination into a secular priesthood. For one, physicians seem to produce signs and wonders. They can see and interpret every layer of the physical body, alter our genes, dispense chemical potions to rid us of plagues, and perform the awesome task of opening our viscera and replacing organs. Even medical jargon, credentials on the wall, and the white coat itself — these seemingly incidental, symbolic aspects of medicine — may matter, just as religious liturgy, priests’ blessings, and ceremonial objects and attire are inherent to religious ritual. But in the medical context, rites, incantations, and objects have substantive rather than spiritual effects. Social scientists have for decades demonstrated the influence of these “non-specific” factors on outcomes like adherence to medical treatment, recuperation from surgery, and especially, improvement in psychiatric illness. So, the white coat holds potential power, albeit through a cognitive and social rather than spiritual or supernatural process. 

To extend the religious parallel, note that doctors are not just serving as secular clergy but also making god-like decisions. At times, medical professionals must decide who shall live or die, though usually with ethics boards peering over their shoulders and patients and families making the ultimate decision. For example, whether an elderly patient with advanced disease should receive risky surgery or face a high probability of death without it presents an ethical dilemma. With this lofty role, the white coat may radiate a holy vibe.

Nevertheless, no medical student signs up to play God. The COVID-19 pandemic placed this in stark relief, raising the stakes of ethical problems and adding new ones: physicians had to make hasty decisions about whom to turn away at emergency departments, without time for measured discernment. No person should have to perform such a task. 

The white coat’s quasi-religious connotation may hover like a ghost in the hospital halls, but its embodiment of sterile objectivity is reincarnated in “evidence-based practice.” All treatments must have an empirical justification. At the same time, contemporary medical education aspires to teach a humane approach including respectful, collaborative relationships with patients and an understanding of the social, economic, and political context for health and illness. This approach tempers the image and softens the practice of the lofty scientist-priest. Although humane interactions with patients may seem like an obvious goal of medical training, some programs give only lip-service to it, and even with thoughtful training, some practitioners never get it.

Psychological research supports the idea that medical encounters are not — and perhaps should not — be above the social plain. For example, we know that physician and patient demographics such as race influence judgements and decisions, well outside objectivity. Emotion and one’s identity are often present in the medical encounter, the white coat notwithstanding.

Soon after budding physicians don the white coat and begin work on the floors, they often get a message: don’t get too involved; care for patients, but don’t care too much about them. As they are grilled on the science, they may be emotionally fried. Despite the academy’s aspiration to more than biomedical science, students still report that some supervisors expect them to maintain emotional distance, superhuman endurance, and a hierarchical social structure. 

In some medical quarters, a macho ethos and intoxication with one’s power persists. Despite reforms like decreasing the overwhelming hours residents work and providing emotional support during medical school and residency, identity formation of the doctor clearly includes becoming someone who can hack it under pressure. While part of professional maturity in any job entails learning to manage one’s emotions, distancing oneself from the patient and from one’s private reactions can go too far.

Emotion in medical care is harmful only if we avoid it. Patients not only seek expertise and professional judgement but also empathy. The late essayist Anatole Broyard noted that he wanted to be “a good story” to his doctor. Perhaps this is what we as patients seek in the medical encounter above all: for our stories to be heard and our humanity understood. We want to be more than “the knee in room 305.” Patients want to receive not just a pharmaceutical communion wafer from a white-garbed high priest of modern medicine but also “communion” in the other sense of the word. When a patient says she “loves” her neurologist, she’s not talking about diagnostic acumen (although that is important) but rather, compassion.

While a myopic view is hazardous to patient health, doctors who ignore their own emotional states are also at risk: chronic stress, burnout, substance abuse, suicide, and other mental health problems plague medical workers. Guarding against both callousness and burnout is a balancing act. A white coat may be easy to clean after a tragic death, an impossible night in the NICU, or weeks of alienating work on a COVID-19 floor, but the moral injury is not so easily remedied.

If the white coat is potentially a harmful symbol of intemperate objectivity, perilous avoidance of emotions, elevated status that distances practitioner from patient, and inhuman standards for a doctor in training, should the spiffy jacket follow its somber precursor into the rubbish bin? Perhaps not. Symbols reflect and confer realities, but we can alter the realty to change the meaning. For example, doctors should not stand while the patient is sitting or address patients by first names unless invited to do so. Doctors must avoid expressions of prejudice and provide compassionate care for trainees. But some physicians have ditched the white coat anyway, along with antiquated social practices. 

The white coat does have a crisp collar, handy pockets, and an easily identifiable glow at a distance. Uniforms have their place. But perhaps there is another reason we should not be so quick to trash the white coat. Despite its potentially insidious meaning, the coat can hold an alternative, salutary symbolism, which discards threadbare connotations. If so, medical students can receive this mantle with genuine honor.

On Yom Kippur, the Day of Atonement, Jews recite the “unetaneh tokef” prayer, which states that God decides at that moment “who shall live and who shall die” in the coming year. It is the most solemn point in the High Holidays. On that day, there is an additional custom that suggests an alternative for the doctor’s white coat.

Jews wear white on Yom Kippur. Traditionally, the white clothing is a kittel, a simple white robe. In fact, it is a shroud, the very one you will be buried in. Wearing the kittel is meant to evoke humility, contrition, and a reminder of our own mortality so that we aspire to better behavior towards others in the new year.

Of course, Judaism is not the only religion or culture to employ white as a sign of mortality or purity. Boatloads of paper have been sacrificed to the analysis of why Herman Melville’s whale is white and why we humans are clothed in it at special times.

Could the medical student’s white coat come to mean, in part, something like the kittel? While the black coat in former times hinted at the patient’s mortality, the white one could embody the doctor’s as well, like the memento mori of the Renaissance. Despite the magic of contemporary medicine, despite the audacity necessary to make decisions about someone else’s life and body, doctors are after all, only human, only mortal. And maybe they — and we patients — need to be reminded of it. Placing one’s arms in the sleeves of the white coat for the first time, with a secular “congregation” present, can ritualize not only emerging professionalism, but also a commitment to humility and to the full humanity of patients, co-workers, and oneself. 

I’d like to add something else to the white coat ceremony, something that revives the color black, though it could also be purple, chartreuse, gold, or rainbow. 

A few years ago, I taught a course to medical students on meaning and medicine. We studied poems, fiction, essays, and films to explore the big questions: love, death, work, illness, religion, and humor. The students wrote and shared their own stories and poems, often spontaneously describing the strains of school, medical rotations, and the implicit message to “just do it.” Even at this early stage, they also described a creeping sense that meaning in their work and in life were eroding. So, our discussions weaved the personal with the intellectual, the literary with the anecdotal, the philosophical with the empirical.

The final class was at my house with a home-cooked meal. At the end, I gave them each a parting gift, a gel pen and a small, lined notebook with a soft, black cover. With some irony, I introduced a “Black Book Ceremony,” and they were invited to use the notebook over time to jot their thoughts, feelings, poems, stories, and sketches. And I added not an oath but a blessing: 

May you sustain confidence without arrogance, compassion without exhaustion, irony without cynicism, humor without disdain, meaning and heart without loss of scientific rigor. May you keep writing and drawing. May relationships, joy and satisfaction in work endure. And in moments of doubt, may you look to each other, to community, and to a sense of meaning in whatever form that takes.

The students took in my experimental ritual with apparent good humor, but they were especially pleased to take home leftover chili and cornbread.

Author’s note: The author wishes to thank Douglas R. Reifler, MD for comments on an earlier draft of this essay.

Image credit: Stethoscope by Rosmarie Voegti licensed under CC BY 2.0.

Wendy A. Horwitz, PhD Wendy A. Horwitz, PhD (1 Posts)

Guest Author

Penn State Abington

Wendy Horwitz’s essays, editorials, and reviews have been published in the Philadelphia Inquirer, Afterimage, Neurology (Humanities Section), Jewish Literary Journal, Intrepid Times, and McClatchy-Tribune News Service, among others. Trained as a pediatric psychologist, she writes and teaches health humanities in the Philadelphia area.