The College Medicine welcomed 173 first-year students into the medical field on Friday, Aug. 9, during the college’s 18th annual White Coat Ceremony. Laura Wexler, MD, adjunct professor of medicine and recipient of the 2013 Leonard Tow Humanism in Medicine Award, gave the ceremony's keynote address:
"I am going to talk to you today about some themes you might not be expecting. For your families and significant others, this is surely a celebration and acknowledgement of your hard work and accomplishments so, absolutely, congratulations to you and your families.
But what I am going to talk to you, waiting there with coats, about is how profoundly your life is about to change and about power and privilege.
What are we about to do?
We will ceremoniously drape you in a white coat, with expectation that this ritual will move you across the barrier between what you are now, sitting there:
Stay at-home parent
Standup comedian …
(we’ve had a lot of non-traditional students), and what you are about to become: a student of medicine, or, more precisely, a student doctor. Why do I call it a ”barrier”? I call it that because the transition is not as easy or straightforward as you think—and is far more life changing than you probably now realize.
I suspect that most of you do realize what you are up against academically and are a bit (or perhaps more than a bit) anxious … and that what you are mostly worried about is how you will cope with the notoriously relentless burden: learning a vast amount of information in great detail at warp speed, with frequent quizzes, tests, evaluations and board exams.
We the faculty, we’re not worried. You all have the tools to make it. You are all really smart and good at passing exams. And while you certainly may struggle at times, and have to consciously work on your study skills and change your study habits, if you stay motivated and healthy, you will make it.
So what barrier have you crossed and what does the white coat mean you have become?
After the white coat ceremony was established, there was some pushback from physicians and medical educators who said it was premature to give new students this symbol of the profession of medicine. They said that you should earn the right to wear it and that you should not be required—or even allowed—to swear to an oath like that of Hippocrates until you have the knowledge, skills and attitudes firmly in place to be able to fulfill that oath.
Others have suggested a dark side to the white coat, suggesting it is a negative symbol of entitlement, and paternalism. One author even suggested that the white coat symbolizes that you are now coming to be aligned with us, the faculty, against the patients, separating you from the lay public … like acolytes in some kind of ancient, secret, priestly order.
Shortly after the initiation of the white coat ceremony, a physician named Sam Huber discussed these arguments in the Journal of Medical Ethics in 2002. He acknowledges that this is indeed a solemn ritual, which, like all rituals, appropriates meaning to an event or, in this case, a symbolic garment. But he argues that this ritual is not an acknowledgement of status or celebration of accomplishment (that’s later … that’s called graduation).
This ritual is an initiation into a new identity, more like a confirmation or bar mitzvah ("today I have become a man”). Today, you swear a very solemn commitment to become a physician and, in so doing, you join this profession now, putting on the white coat that symbolizes the best and necessary attributes of that profession: virtue and excellence. But the white coat, like many important symbols, can have both good and evil connotations. Be mindful of and resist, resist the evil temptation to regard your white coat as a "mantle of privilege.” Because to your patients and the public, the white coat is the "cloak of compassion.”
Now, you may sitting there and saying in your heart of hearts, "that’s later when I am a doctor, now all I have to is study hard so I will succeed, I will pass my courses, I will get good grades, I will pass Step 1, I will look good on my rotations so I can get good evaluations, and match into the residency I want … I, I, I … me, me, me.”
Make no mistake: when you stand up and leave this room today, you are now and forever a member of this profession and expected to live by those high standards of virtue and excellence, which include compassion and altruism—putting the welfare of others foremost and at all times. Anyone who sees you in your white cost, or who identifies you as a student doctor or whoever will encounter to as a student doctor, during work hours or after, in the medical school, in the hospital in the parking lot, at your apartment complex, at a bar on a Saturday night, on Facebook now identifies you a student physician and associates you with standards of our profession. And that also goes for your colleagues, the person sitting next to you. Before too long, your classmates will also begin to see you as a professional colleague. How can they not? It’s you they are going to be referring their parents and children to in the future. Would I send my kid to somebody in my anatomy group?
So, your life has really changed. And it is crossing this barrier, assuming this new identity, that is most profound today.
Now: privilege and power. Think about how and why most people work. The majority of people on this earth work to survive, often at mind-numbing, body crushing jobs with no security. As a physician, you can look forward to continuous secure, gainful employment doing meaningful, intellectually stimulating work for which you will be thanked and financially rewarded. This is a great privilege.
You will also wield, even as a student doctor, enormous power over people. When you enter a patient’s room to do a practice history and physical, which you will do within the next few weeks if not days, based on nothing but the power of the implicit trust conferred by your white coat, and the name badge identifying you as a student doctor, people old enough to be your parents or grandparents will tell you the most intimate details of their lives and then they will disrobe and permit you to touch them.
As my all-time favorite philosopher Peter Parker said, "With great power comes great responsibility. This is my gift and my curse.”
If you accept this gift of power and privilege, symbolized by this white cloak of compassion which tells people "I am a doctor … I care for the sick and the troubled. I am here to care for you, ” then you also accept the awesome responsibilities of being worthy of it. That that starts right now, today. This unrelenting and intrusive responsibility may often seem like a curse, and your white coat, a symbolic hair shirt, lifelong study, endless homework, long hours and, as Garrison Keillor might put it, continuous service to Our Lady of Perpetual Responsibility,
Are you proud? Are you humbled? Are you scared? I actually suspect that a fair number of you are dubious, maybe even a bit, may I say, pissed off that I am laying this heavy melodramatic trip on you. And indeed, many things about medicine today will distract you from this message. You will observe and hear a great deal that seems to undermine, undervalue and even deny the importance of the doctor-patient relationship. Technology, genetics, advanced molecular imaging … if diagnosis and treatment is a science that does not require verbal or tactile interaction with the patient, why not outsource the face time with the patient to someone who does that for a living, or even program a compassionate avatar so the patient can talk online and you can do more procedures and order more tests? And then there is the business of medicine: billing and coding, more throughput, increase reimbursement, market share ….
Maybe this is also part of the blessing and the curse of privilege and power: We are the most powerful nation on earth, blessed with unparalleled science and technology. Fueled by the powerful post-World War II economy, we created a magnificent health care system over the past five to six decades. But it is beset by inequality, inefficiency and uncertainty that threatens to distract physicians from their core moral obligation to put patient care first. I’m glad to say, as a whole, physicians don’t like this and we want it to change. And, as in the last Spiderman movie, it may get ugly for a while, but physicians have great power, our patients need us, and we will do the right thing.
But back to you and your new identity, and to the themes of power and privilege, your blessing and your curse: I’m assigning you two pieces of homework, one to do alone and one with colleagues. First, alone, go to your computer, close your eyes. Imagine that the person you love most in the world has been sick for a few days and now tells you they might have pancreatic cancer. They are sick, scared and in pain. They have been referred to a specialist who will see then tomorrow. They give you the name and ask you to look the doctor up online. The name is yours.
Now, open your eyes, and go to your Facebook page. What do you see? You have a new identity … today! This is true, the patients assigned to you in student clinic will look you up! The boundaries between your private life and your public life have shifted. You are not always on duty, but you are always a member of this profession, in the hospital and out, during work hours and off. It is not overstating it to say that maintaining the trust of the public is a sacred obligation. Guard your reputation, do not disappoint your patients, bring honor to our profession.
Second: gather a group of friends and watch the 20-minute TED talk given by Abraham Verghese, the author of My Own Country, which you are currently reading. It will restore and inspire you after this rather gloomy and serious talk. It is about the power of the physical exam, and the role of talk and touch in sealing the doctor-patient relationship and overcoming the fear, anger and despair that are the enemies of healing. Only a physician can do that in person, in contact with the patient. The most sophisticated technology is worthless to a sick patient if they do not trust the doctor who recommends it.
Continue to ruminate often about the power and power and privilege this white coat confers … and the awesome responsibility. Use it wisely and be worthy of it."