Tuesday, September 9, 2014

White Coat Blues

Editor's Note: You might be interested in reading a follow-up post, published nine months later, "White Coat Blues, Redux."

There is a certain aura surrounding the white medical coat. You probably know that it is modeled after the laboratory coats scientists began wearing in the late 1800s. Like the traditional white nurse's uniform, it represents aseptic modernity, free of blood and other bodily fluids. When my elementary school social studies teacher ran a lesson on science and medicine one year, we had to bring a white jacket or sweater to wear to class as a form of dress-up. During that unit, I imagined what it would be like to discover a cure for cancer or AIDS. I also remember having to ask a classmate to borrow her sweater on more than one occasion, having left mine at home.

Most medical schools hold a "White Coat Ceremony," at which students are inducted into the hallowed sect of white-coated healers who promise to "do no harm." Some schools do this right at the beginning of the four-year curriculum; we had to wait until the start of our second year. It was a big deal: many students' families came from out of town; professional portraits were taken. Afterward we hung our two white coats our closets until the time, a few months later, when we were finally released onto the wards to see patients.

There I was confirmed in my suspicion that the white coat is an ambiguous symbol. Many physicians refuse to wear one for being too formal. In fact, my own clinical adviser had to borrow one before our ceremony. In the hospital, some other "para"professionals wear white coats (phlebotomists and physician assistant students come to mind). Even after introducing myself, patients have sometimes mistaken me for a nursing student.

I feel the weight of my white coat keenly. For one thing, it's laden with a stethoscope, a "white-coat clipboard," a pager, two tuning forks, a reflex hammer, and a neuro kit. It's always "a jingle-jangle morning" with me on the wards.

For another thing, it's short. The medical student "jacket" comes to the upper thigh, as opposed to the knee-length "coats" of the residents and attendings. Savvy observers read the length of our medical training in the length of our clinical "outer wear" and frequently assume that we are young (and therefore immature) in addition to inexperienced (no debate there). Some of my dual-degree colleagues have commiserated with me about the way the length differential marks us out of the flock of white coats--we who already have terminal degrees and a great deal of knowledge...about something completely different. It can feel infantilizing, like knickers on British schoolboys.

And yet the white coat (and appropriate institutional name tag) is my ticket into private places and sensitive situations. It allows me access to most parts of the hospital, to stand in the corner in the ER when a patient has just been rushed in, to ask personal questions of people I have just met minutes before. I've been mistaken for a doctor, too (the "real" kind).

After graduating with my PhD this spring, I took my coats to a local shop to get ", PhD" embroidered after my name. Occasionally a patient or attending will notice and ask about it; but with a name as long as mine, I think the extra letters end up in my armpit more often than not. One of the attendings introduced me as "Dr." once or twice, but it turned out to be too awkward and take too much time for an explanation of how I was a doctor but also a medical student, so it was quickly dropped, to everyone's relief.

Before I made the transition from graduate school to medical school for the second and final time, I had predicted that it would be rough. Certainly the first time that I traded a seat around a seminar table once a week for a seat at the back of an auditorium for four hours every day, I chafed at the different power dynamics and intellectual expectations between graduate and medical school. (I describe these feelings in a conference paper, "C.P. Snow Goes to Graduate and Medical School," recorded after the fact.) Others who have navigated these things reassured me that the necessary knowledge would come back to me, and that I would soon function as a member of the team.

Nevertheless, the first couple of weeks were tough, partially because I had given up my dedicated study time to work on turning my dissertation into a book manuscript and was therefore flying by the seat of a pair of pants that was four years old, and partially because of various supervisors' uncertainty about how much they could or should expect of me. At one point I wrote this facebook status update:
I wish that I could bottle the feeling of frustration, confusion, and not-knowing that is so common to third-year medical students--and probably interns, for that matter--so that I could sell it as a rejuvenation tonic: Eau de l'enfant. I am two years older than our attending (a great guy), but pretty much every day my resident makes me feel half as old (usually not intentionally). — feeling small.
It garnered me some sympathy and encouraging words from friends who are farther along than I am. That was enough to get me to the point at which my residents and I worked well together. Then the residents changed, and I was back to square one--but only for a few days this time, instead of a few weeks.

Now I am nearing the end of my third clerkship, and I feel confident about my ability to talk to patients by myself, to take a sufficient history, and to do a basic physical exam. I also write pretty good notes, for a third-year medical student. I still think slowly on my feet and sometimes have to go back to ask more questions or check something out, but I know that clinical acumen will come with time and practice. Most of what I do is for my benefit right now rather than the patient's--my name seldom appears in the chart, and the residents and attendings have already figured out what the problem is and how to treat it. For now, I am happy to put on my white medical student jacket and "play doctor" almost every day. It's a childhood dream come true.

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