It's time to hang up the white coat

This morning’s New York Times Week in Review section has an article on the white coat and the concerns about contamination by microbes. In a previous posting, I discussed the infection control aspect of the problem with white coats, and the magical thinking held by most physicians that somehow the coat has received a dispensation from the germ theory. Perhaps as interesting as the infection control angle is the issue of the coat’s symbolism and its link to professionalism. There are several papers in the medical literature that discuss the coat’s symbolism. The positive symbolic aspects include candor, integrity, and goodness. Also, it is viewed as a symbol of purity and cleanliness, which is ironic given that two-thirds of doctors wash their coats no more frequently than every two weeks. Negative symbolism has also been described. Some view the coat as a symbol of hierarchy and authority, a marker of social and economic privilege, and a way to denote that the physician is part of an elite community somehow separated from the rest of society.

Dr. Judah Goldberg, an emergency medicine physician and ethicist, wrote a compelling paper in Academic Medicine last year, in which he compares and contrasts professionalism and humanism, and how the white coat fits into these constructs. It's a must-read for those interested in the white coat debate. He writes that one comes to understand humanism simply through the experience of life, whereas, professionalism is acquired through the socialization process of entering a profession. Humanism’s motivation is to serve the welfare of humankind. On the other hand, professionalism’s primary motive is to strengthen professional identity. Most importantly, Dr. Goldberg points out that the outcome of humanism in medicine is to link the physician to the patient. The outcome of professionalism is to separate the doctor from the patient. Thus, once the differences between humanism and professionalism are delineated, it becomes apparent that the white coat serves the latter.

Another physician, Dr. Matt Bianchi, in a paper in the Journal of General Internal Medicine, is able to distill the entire issue into a few sentences as he writes about his own experience:

“I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.”

In the end, the white coat is all about the doctor, not the patient. The New York Times article quotes a physician who says, “The coat is part of what defines me, and I couldn’t function without it.” Now that’s magical thinking at it's finest!