By Jason Lippman, MD
For a century, the white coat has been the symbol of the medical doctor. Today, the vast majority of medical schools in the US begin with a White Coat Ceremony. There, the fledgling, future doctors stand together and recite a modified version of the Hippocratic Oath before being called up one-by-one to receive the white coats that they will wear throughout the upcoming trials and adventures of medical school. The White Coat Ceremony, started at Columbia University in 1993, is intended to create “ a psychological, intellectual, and ethical contract for the profession and promotes empathy in the practice of medicine from the very start of medical training.”[i]
The tradition of the white coat initially formed in the early decades of the 20th century. Prior to that, doctors actually wore formal, black attire rather than white. White coats are thought to have been adopted in a conscious effort to 1) mimic lab coats and create the image of doctors as people of science, and 2) to pursue the concept of sterility in medical care that was becoming important at that time.[ii] Both aims were meant to set doctors apart from the common man and, since its adoption, the white coat stood as a status symbol. It transformed a person into the embodiment of medical science – like a white knife cutting through the contaminated world of death and disease – pure and superior in her knowledge and treatments. To go along with this, as doctors advance in training they typically receive longer and longer white coats – enhancing their prestige and image.
While the White Coat Ceremony has tried to create a new conception of the white coat within the medical community, public perception of the doctor in the white coat retains the prestige of paternalistic medicine. Multiple studies show that patients not only perceive doctors in white coats as more competent but that laypeople even perform better at tasks when wearing a “doctor’s” white coat.[iii][iv] Like a shaman’s costume or the face paint of a witchdoctor; the white coat appears to create a psychological power behind the care we provide.[v] It says, “Trust me, I’m a doctor.” This potentially adds a powerful placebo effect to the proposed treatment; however, my concern is that this disrupts any intimacy and familiarity within the doctor-patient relationship. So while the data may convince me to start wearing a white coat for board exams, I continue to wonder if it would be both a physical and psychological barrier between me and my patients in the exam room.
As an empathic student-turned-doctor, over-formality in the way we dress has always worried me. In the world of primary care, bonding with and motivating our patients is the key to success. This is particularly important in the prevention or care of chronic disease – the major challenge for the health care system. Here, success is going to be determined by our patients’ commitment to their health. It’s crucial that they are part of the conversation, because all the medical knowledge in the world is not going to provide long term benefit to a person if we don’t understand what obstacles are keeping them from consistently picking up their medications or coming to appointments. The pursuit of health is a team effort and it is important to establish that we, as their doctors, are their partners in the journey. Our approachability, or lack of it, can be enhanced simply by the way we dress. We find the exact point in the idea of “white coat hypertension.” While patients respect a doctor in a white coat, it does not necessarily bridge the gap between the doctor and the patient in the way the White Coat Ceremony might imply.
I will admit, my transition to a life and career in Utah has given me a new perspective on this dilemma. Here in Salt Lake, I suddenly have found myself comparatively formal in my clinic attire. I regularly get poked fun at for wearing a tie to clinic, while everyone else nonchalantly leaves their top button unbuttoned. “Going to a funeral? This is Utah; what’s with the tie?” I appreciate the relaxed atmosphere of our clinics; however, the tie is a habit I haven’t been able to break – and one I’m not sure I want to. A tie helps me feel confident. I feel like I’m showing my patients respect and that I look the part. Stepping back from it, it really isn’t that much different from the idea of the white coat. Maybe the meaning of our clothes is as much in the mind of the wearer as it is in the eye of the beholder. Maybe the witch doctor needs to wear face paint as much as the patient needs to see it – the physical transformation gives the doctor the confidence to present himself in a way that is powerful and convincing.
Most likely, the solution is simply that medical providers should dress in a way that is true to their self-image as doctors and mentors. Ultimately, I would hope patients will connect best with doctors who are comfortable in their appearance. If you feel that a white coat is part of who you trained to be and you wear it with meaning, I am sure patients will respond to the attire with respect and trust. For many, patients will appreciate the symbol regardless of how confidently a doctor makes it part of his or her image. I just hope that we don’t use white coats simply as a status symbol. I truly believe the hope for the future of medicine lies in engaged, humanistic partnerships with our patients. Hiding behind a white coat, or a tie, or anything else, with the hope that it will buy us respect and compliance is not enough. Whether we dress formally or casually, conscious thought should go into how we are presenting ourselves as doctors and how our attire may be perceived by our patients.
Jason Lippman, MD is an Intern Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.