Germs & Politics: Why I Don’t Wear a White Coat


Imagine this: Your friends and family are gathered in the main auditorium of a 200-year old medical college. The air is abuzz with excitement. You are sitting in reserved seating in the front row, among the others in your class who are also about to be indoctrinated into a special society. You are wearing a dress purchased just for this occasion because it’s that important. Eventually you are called onto a stage where the most esteemed faculty of the medical school await you.

You walk up the stairs to the stage, all eyes watching. It’s your turn to pass through the row of handshakes, pats on the back, and welcomes from the line of medical greats from each department, those who selected you to join their ranks and who will guide your mind and hands for the next 4 years of training. As you walk and are welcomed, your accomplishments are being read aloud for all to hear – the accomplishments that have set you apart from and above most of the rest of the American public. The audience is told, in fact, that you are in the top 2% of thinkers in the US and you have earned this spot above all others save the 99 other people going through this ceremony alongside you today in this hallowed hall.

You are then enrobed, by the last physician in the line, often the dean or president of the medical school, in a special white coat with your name embroidered, usually in red or blue thread, above the left breast pocket.

Welcome to the Other Side: The White Coat Ceremony

This magical robe is called “the white coat.” This ceremony is real. It is called the White Coat Ceremony. Since the 1990s, more than 90% of American medical schools have adopted it. I went through it. It is the moment recognized in medicine as when people go from being ordinary civilians to being publicly endowed with the magical powers of being a doctor. Indeed, it is perhaps the most symbolically meaningful ceremony a young emerging doctor goes through – often even more pregnant with meaning than the medical school graduation (which is really just a long boring ceremony and a party before beginning the grueling residency process, so not too exciting!), and certainly more elaborate than the near lack of ceremony that accompanies completing residency.

Donning this magical white coat, you cross into another world. One historically reserved for those with the healing powers of the gods. Asclepius, one of the earliest physicians who gave us the symbol of the doctor’s staff entwined with snakes. Hygiea, the goddess from whom the word hygiene is derived. The American Medical Association with its self-empowered authority.

Wearing this magical coat has an amazing effect on others. In fact, the white coat was initially adopted by physicians in the late 19th century to improve the then dubious reputation of doctors in the eye of the American public. Nowadays, it is a symbol of trustworthiness, so people believe what you say – just because you are wearing it. The white coat itself carries the very meaning of authority and cleanliness. That authority is part of the point of this story. But back to that soon.

The length of the white coat is also symbolic. Medical students wear short white coats that graze the top of the hip. Residents, though still in training (specialty training), but who have graduated from medical school and now carry “MD” after their names, as well as senior doctors, wear longer white coats. These extend to the hip or knee. Medical students are not permitted to wear the longer coats. While patients don’t know the meaning of difference in the coat length, it represents a very clear hierarchy in the hospital. In fact, in residency programs where “first years” or the interns are required to wear the short coat, they consider it insulting and infantilizing. In the realm of Olympus, it sets the older, seasoned doctors apart from the younger ones, who at times, appear still half-mortal, though the youngsters think themselves increasingly invincible. Coat length is a big deal in a “mine is longer than yours” club!

(I used to joke that longer coats equal deeper pockets. But that’s not really true. Medical specialty ultimately dictates that!).

The White Coat and Doctor Powers

Wearing this magical mantle day after day in the hospital and clinic tacitly imbues you with the power to do amazing things that no other human beings can really do in any other environment. For example, you can instruct people to take their clothes off and then sit up on the exam table wearing just a paper thin gown that barely even closes in the back (and if you are a woman going in for a gynecologic exam, you are to put it on with the opening in the front) while you prod them with questions and then an exam.

It gives you permission to delve into the most personal aspects of patient’s lives – and their intimate body spaces – on your own timetable. This is typically after they’ve waited weeks or months to get an appointment and have waited through an hour-long wait in the waiting room, for an appointment that only lasts 7-15 minutes – the average wait-time and length of a doctor’s office appointment for most people.

It gives you the power to make decisions over other people’s lives – and death – while having one eye on the patient and one eye on the clock in a medical world where time literally equals money. It gives you the authority to make errors and not apologize. Of course, we are told that this coat also carries with it responsibility – we take the Hippocratic oath wearing it – which states that our primary goal is to “do no harm.” Most of us do try to live up to that, albeit with faulty and ever-changing information on what we do that actually does and doesn’t cause harm – from the tests we do to the medications we prescribe to the procedures we practice.

To the patients in the hospital and clinic, the white coat is a symbol of authority. Now this is not all bad – it lets patients know that you actually are a doctor, and not a nurse (very different uniform, pastel colors and all), or a cleaning person in the hospital or clinic. It also tells patients “this person knows what he or she is talking about, has your best interests in mind, and knows how to heal you.”

White Coat Backlash

However, the white coat does not make all – or any – of these statements necessarily true. In fact, wearing a white coat perpetuates these myths about medicine. It also creates a hierarchy – I’m the almighty and important doctor, you’re the patient.

For some people, many in fact, the authority of the white coat has a backlash. It stresses people out. This is commonly seen in the condition called “white coat hypertension.” This is a phenomenon whereby people’s blood pressure is high enough at the doctor’s office to actually get diagnosed with hypertension and put on a medication if it happens at two different doctor’s office visits! The U.S. Preventive Services Task Force has just issued a recommendation that patients be given home blood pressure cuffs and if they are normal at home, not be diagnosed with and treated for high blood pressure if it is higher when at their doctor’s appointment.

Of note, white coats also typically scare the heck out of kids. It’s why most pediatricians don’t wear them into patient appointments. They wear plain clothes, like the rest of us, making sure to look professional but not scary. Sometimes they have toys in their pockets. They are, however, no less authoritative without the coat. Or with the toys.

A New Way of Doing Medicine Means Letting Go of Outdated Ways

So why am I telling you all of this? Well here’s that part of the story about people believing what people in white coats say. Lately, I’ve been noticing how many blog space health “authorities” are donning white coats in their banners and marketing pictures. And some aren’t even medical doctors! And I think this is really confusing to you, as consumers, when you are trying to sort out what health information to trust. Wearing the white coat is meant to give them an aura of medical authority to you, the health information consumer. It’s meant to say ‘trust me, I’m a doctor’ – which is perhaps the most tacitly implied message behind the white coat. It is designed to make you think you are getting accurate, well-researched information from a recognized health professional. Sometimes you are; sometimes you aren’t. It is intended to subliminally make you not question their authority. Because studies show, we generally don’t question medical authorities.

The fact is that anyone can buy a white coat and have their name custom embroidered on it. You could do it right now with a simple Google search if you wanted one. You can even buy and wear a long coat.

I don’t own a white coat. I mean I really, truly, literally don’t have one. Not at home. Not at my medical practice. Twice recently, I’ve been asked to wear a white coat for marketing purposes – once for an herbal medicine company, and once on a national medical television program. I declined both times, explaining that I don’t wear a white coat for political reasons.

I stopped wearing a white coat before I even finished residency, with exception of when I was doing office procedures like lancing festering abscesses or removing cysts. But that was really just based on a bad experience with some flying pus one day when I wasn’t wearing a white coat for a procedure. Actually, it’s for this very reason that white coats are entirely unhygienic. There’s been a small movement to get doctors to hang them up for good. You see your doctor wears it from one appointment to the other, one hospital or exam bed to the next, leaning over patients in hospital beds and then examining you. Unlike clothing which lies close to the body, the white coat brushes the edge of the bed and the patient before you, then you, then the next patient. The doctor also examines you with tools that he or she then sticks back into the white coat pocket without cleaning them off first. (I am one of the few MDs I know that actually wipes the head of my stethoscope off between patients.) And like I said, flying stuff gets on them.

So why did I stop wearing a white coat? And why I am chagrined to see so many MDs and non-MDs in the integrative health and medical space wearing them as “evidence” of authority. Hygiene issues aside (though important and worth considering), I stopped wearing mine because I don’t like what it represents. To me it is a symbol of medical thinking that I want to see changed along with seeing changes in the type of medicine we offer. The white coat represents an outdated uniform – an expression of membership in an exclusive (male-dominated) club. In fact, when I got into Yale medical school, an MD colleague hugged me and said, “Welcome to the boys’ club, sister.” She was kidding, but I knew what she meant. It was meant as a compliment: “You have arrived and now have some major caché, girl.” But I believe it’s time for something very new in how we doctors see ourselves. We need to be part of the regular human club, not the country club.

I believe doctors should be in partnership with our patients – not separated from them by an implied cloak of superiority of knowledge, represented by the white coat. While of course, I want my patients, and you for that matter, to trust me, to feel confident that I am an authority in the information you are seeking from me, I don’t want you to be intimidated by me because of my white coat, and the data suggests that patients are intimidated by the white coat, just as we are with any other uniformed authority figure. Intimidation doesn’t usually lead to honest, comfortable conversation or a healing relationship for the patient. The healing relationship is very important in whether our patients will actually follow recommendations and get well.

And while yes, perhaps it would make my day faster and easier if you did not question my “authority” – on a very busy day I might even imagine the fantasy patient who just does what I say since I know it might really help them to feel better and will take less of my time than explaining everything – I actually want my patients to question authority. Not just mine, but medical authority in general. Medical errors, in fact, are one of the leading causes of death in the United States, and “absolutely true” medical guidelines are discovered to be not so true – and change – almost daily in general and specialized medicine.

In just my own three years of residency training, long-held beliefs and practices changed because we discovered we were over-treating or doing things that were unnecessarily risky for patients. Here are just a few changes I can rattle off the top of my head (that is, without a Google or PubMed search): when to use aspirin to prevent heart attack and stroke, whether to use hormone therapy in women to prevent heart disease, raising the blood pressure number at which otherwise healthy people over 50 should be treated, the proper blood sugar number at which to start treating for diabetes, how often to get a pap smear, whether statin drugs are safe and necessary for prevention of heart disease in otherwise healthy women, how often to get a mammogram, the safety of many mood stabilizing medications, reconsideration of the benefits of prostate screening for men, and when in pregnancy it is acceptable to do a non-emergency cesarean.

Back to that white coat hypertension, as many as 15 to 30% of people who are found to have high blood pressure in the doctor’s office don’t actually have high blood pressure as a disease. For years now, people have been receiving medication for what turns out to be white coat hypertension. Ironically, we end up writing the prescriptions in our white coats!

A Call to Divest from the White Coat

Now that sounds to me like a medical system worth questioning. It’s one of the reasons you’ll rarely, if ever, find me in a white coat. Though as an MD I did pass through the ranks of “short coat” to “earn” a long coat and be considered a medical authority, and I loved my medical training at Yale, I prefer my authority to come across in what I know and share, the benefits my patients (and readers) have experienced, the skills I’ve gotten through clinical and other training, and the wisdom I have earned from being in practice with real human beings for 30 years (as a midwife and clinical herbalist, then as an MD). I’d love to see all of the amazing health bloggers who are contributing to a new and sustainable, functional model of health divest of their white coats as we divest of hierarchical, “doctor as god” old ways of thinking into our new model of health and healing.

 

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Mary Kathryn

Thank you, and thank you again. I've had some terrible experiences with doctors, since 2 of my wonderful, talented children came into this world with very treatable, but difficult disabilities (binocular dysfunction, and from birth, a milk allergy that by age 2 was decreasing her brain development..honest! We figured it out at age 13, but she flew through her growth once we got her on track.) But those two children, as well as the other two, are happy, college educated, functional adults that moved forward because I bravely ignored what most doctors said, and listened to the ones like you who said keep trying, there is something out there to help. (aka, I, the doctor, don't know everything.) It still brings tear to my eyes to think how hard I had to fight for my daughters, and different tears to know that medicine and common sense are still the best combination. So, thank you for giving us a big green light to trust our instincts, and to keep searching for someone, anyone, who has answers to what ails us.

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Audy

Long but very insightful. Thank you.

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    aviva

    Yes, LOL! I do write long blogs. :)

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      rita s

      Love your posts. Once had a doctor tell me ( A little knowledge is a dangerous thing), because I always ask questions. I said, (total ignorance is even worse). If he can be educated, why can't I?

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        Megan Liebmann

        Hi Rita, This is Megan from Dr. Aviva's team and I just want to give you a HUGE virtual high-five. Keep on it and you are an inspiration to all! <3 Megan- Dr. Aviva Romm Nutritionist

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barb james

Thank you for your authenticity......I feel inspired that there are doctors like you who are not puppets on a institutional string and you have given hope to many who are seeking the truth.

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apelila

Down with the white coats! lol I hate to be of the "question authority" mentality at my age, but I recently saw a doc for the sole purpose of getting paperwork completed for medical disability. I made this clear when I made the appointment. They still only allotted 7 minutes for the appointment even though my doc is incompetent on the computer where the forms have to be completed. She charges my insurance company for an "extended" appointment, then tells me I either need to schedule a colonoscopy or take home the cardboard stool test kit so she can get paid for the appointment. I have hashi's and CFS...nothing indicates a need for a stool test or more invasive expensive test. I have horrific fatigue and brain fog...the only "help" she has offered in the past are antidepressants to "motivate" me. I laugh at her and would never recommend her, I wonder how she got through medical school.

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Amber H.

Amen sister! I completely agree! I loved this " We need to be part of the regular human club, not the country club. I believe doctors should be in partnership with our patients – not separated from them by an implied cloak of superiority of knowledge, represented by the white coat." Thank you.

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Kelli

I ve given up mine, I used to wear it in the hospital when I worked inpatient because it was required and it allowed me to wear tank tops to work;) Now working in the outpatient setting I never wear it, I now work for a university hospital and I use my lab coat to lay on when I lie on the floor for meditation during my lunch break :)

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Vicky

In the laboratory we take off our white coats before leaving the lab because it is used to protect us from chemical, microbial and radiation contamination! In the hospital nurses such as clinical specialists and nurse practitioners are called "long coat nurses". As a nurse midwife I do not wear a labcoat because it makes the baby's siblings cry - they think I am going to give them an injection. Not wearing one also removes a barrier to building a warm, caring relationship with my clients. I couldn't agree more with this blog!

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Barbara Sinclair

YOU ARE AWESOME, Dr. Aviva! You are smart and brave and open-hearted, and you are one of the pioneers changing the ways of Western medicine by bridging it with alternative methods of healing. Fiercely written! :)

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    aviva

    Oh my goodness! Thank you!!!!

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Elizabeth Carver

Dear Aviva! This is one of the many many reasons that so many of us absolutely love and trust you. I wish I could find someone like you near me. Lots of love and light Elizabeth Carver

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Suzy

Awesome post! I am a pediatrician. I have never worn a white coat at work for many of the reasons you list. I don't want to rely on a uniform to suggest I am competent. I'd rather take that on fully myself through the relationships I build and the medical advice I give. And really, ALWAYS, the expert on the child I am seeing is the parent, not me. So, if anyone is to don a white coat of knowledge during our visit, it is the mom or dad. Over the years, they have been my greatest teachers about children.

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    aviva

    So great to hear from you, Suzy! I bet there are some mommas on this list wondering where YOUR practice is! So many families are looking for open-minded pediatricians.

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Junebug

One thing to consider too is the energetic clutter that lodges in the coat. I know several cases where the dr was getting mysteriously ill and it turned out that all the patients fears and negative energies were in the coat that isn't washed or cleared every day. That's probably too woo woo to discuss though. It would be great to have scheduled energy clearings in the hospital itself. Maybe in 20 years!!!

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angelica

Absolutely love it. Empowering people to take responsibility for themselves and their health by being an active participant in their health.

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Carmen

Right on, Dr. Aviva!! Right on!

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Joanne Oyer

Fascinating. Thank you.

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Abrar

I'm so glad you posed this article Dr. Aviva, I'm a university student studying bioinformatics, and I am concentrating on Medical research (but my research is herbal driven ;) And even on the undergrad level wearing a lab coat in our labs signifies the same things you mentioned, it even causes professors to question your behaviors less!

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Jessica Cowan

Thank you for writing this post. My mom experiences high blood pressure every time she sees her doctor because she's scared of what the doctor will say to her. I remind my mom that she is in control over her body but she still sees the doctor as the ultimate authority.

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    aviva

    Fantastic reminder, Jessica! It's hard to shake the doctor as authority image. And to some extent, for some patients, perhaps that's part of the "magic" in the healing that can happen. But in the wrong hands, that authority can be really detrimental to patients.

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Jean Oswald RN CA

Aviva - you ROCK! Thank you for leading the way toward more "partnerships" between doctors and patients. As a hospital nurse I saw many a white coat intimidate patients into forgetting their questions and nodding their heads in agreement with what the doctors told them, only to confide in me when they left the room that they didn't know what their options were. In addition I had a real beef with doctors who didn't wash their hands between patients. And their ties are another issue like the white coat getting sprayed on! There was a lot of MRSA and ORSA on our floor! Thank you for coming alongside each of us and opening this door to conversation :)

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    aviva

    Thank you Jean!

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Karina Milnes

I am a nurse working in New Zealand and I am glad to say that the white coat appears to be an endangered species here. In this day and age of technology, and freedom of information on the internet, I believe that doctors need to start working closer with other health professionals, and patients, in delivering care. People’s knowledge of health is increasing, whether in a good way or a bad way, and it is only through open honest discussions that people are going to receive care that is suitable and appropriate for them, their condition, and their lifestyle. I have worked many years in operating theatres, and although there has been a decrease in the perception that surgeons are gods, there is still the belief that they know it all, and they are not interested in collaboration with the rest of the theatre team. You couldn’t pay me enough to be a doctor! I have a huge amount of respect for the amount of training, and the working hours they put in, however it is time to start working as a team. Cleaners and health assistants also have valuable insights into our patients, as they often have time to talk to them!

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ML

Loved hearing this honest insight from a MD herself. Thanks for "hanging up" your white coat!

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Jan Davidson

Totally agree with you! Awesome to finally hear someone in the profession to be calling for a change.

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Meghan

Yes!! I loved everything about this. Thank you, Aviva!

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Sylvia

Excellent post! So inspiring, thank you!

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bj tuininga

Thank you for your continued insightfulness into your patients needs! Wish I lived closer to the Berkshires! But I am learning so much from you... so grateful for the knowledge that you share!

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Mélina Bernhardt

Aviva, I loved reading your article. It makes a lot of sense to me. Intuitively uniforms don't feel right in general. I wish there were more available and affordable doctors like you! In Fort Collins, CO I cannot find anybody. Dr J Fields' practice is full and very expensive... ♡

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YE

I wish I lived near you. You would be our family doctor. I am in MO. I really need a doctor like you for my family.

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Sharon

Thank you for sharing Aviva! Agreed! When I was working as RD in hospital and medical complex, my colleague love wearing white coat. I always found it unhygienic.

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Ahimsa Porter Sumchai MD

i am a UCSF/Stanford trained Black female physician with an MD Ph.D equivalent. In 1982 I became the first Black woman to train in Neurological surgery in the UC System. In the 34 years of my career I have been mistaken for a janitor, a nurse and a pediatrician.

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    aviva

    Congratulations! That's incredible. I'm sure the mistaken identity is very painful. Sadly, as women docs, even in white coats, we've all been called nurses! Go you on your career! Amazing.

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Ahimsa Porter Sumchai MD

I wear a carefully laundered full length white coat with my name proudly embroidered on the pocket to establish my identity. Your white skin may confer protection of your professional identity I am not privileged to enjoy and I will never hang up my white coat! I suspect your journey to become an MD was not fraught with the obstacles and hazards I faced growing up in a San Francisco Housing project like I did.

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    aviva

    Probably not, but you might be shocked to discover that I grew up in a housing project, too. I am the first woman in my family to graduate from college, and I have been emancipated since age 15 and on my own. I could go on, but won't. So we all have our own struggles; I respect yours but also ask not to have assumptions made about mine. I had to overcome some major obstacles, too. And I would not put my patients health in danger with the bacteria on a white coat,regardless. Thank you.

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L. Carl Robinson

Good day Aviva. This is my first time to your blog. Impressive and informative. Great work. I work with a DO physician who works at one of the local medical clinics who is also my personal physician. He is very sensitive to the White Coat Hypertension phenomenon and has noted to me that it's very real and something he determined sometime ago to not perpetuate. The only time he wears his white lab coat in the office is when he goes into the lab that is shared between his clinic and the hospital where the clinic is located. When he meets a patient he takes the coat off in front of them and purposefully hangs it on a hook. The visual message this conveys works. He has noted to me that patients bp's he monitors are much more accurate to their home-based bp's as opposed to what he was experiencing a few decades ago when he did the white coat uniform thing. Though my own bp's he monitors are still a bit above what I get when I self-monitor at home, they are close enough for him to get a more accurate picture of that aspect of my health needs, unlike what I experience with much higher bp's when the white coat clad insurance intake practitioner takes my bp's (probably exacerbated by the fact it's also for insurance purposes as well...) Interstingly, I've found MD's to actually be more open to the problems of White Coat Hypertension phenomenon that DC's have been, as DC's appear to think and feel it is an MD problem, to the point some get very testy about their professionalism being challenged when the subject comes up, even though they like to think of themselves as being more patient-friendly than MDs or DOs. It's a weird paradox indeed.

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Beth

Do they really tell the medical graduates that they are in the top 2% of thinkers in the country?! By whose standards?! Those doctors should really get out more. :-)

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    aviva

    Yes, well, at least at some med schools! :) Sadly, not much time for docs in training to get out much!!!

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Pamela

In acupuncture school, we had a 'white coat' ceremony. We were required to wear the white coat in clinic. I graduated in 2011, and only keep it at the office (in the closet) in case someone gets chilly. It actually looks nice on my receptionist, but she is not required to wear it. After consigning the white coat to the closet at work, I wore the same kind of nice clothing I used to wear in corporate America. However, eventually I realized that having an outer, washable!! layer would be more hygenic than my usual 'street' clothing, and allow me to stay warmer, too. Scarves got in the way and were dry-clean only. Plus, as a woman, I find that female clothing often lacks the functionality of similar items of men's clothing. I think having pockets is REALLY useful. So I bought a lab coat - but it is BLACK. Most people probably don't recognize it as a lab coat. Thank you for this article. I forwarded it to some other community acupuncturists, who definitely agree with you about the dynamics of Power Over as symbolized by the White Coat.

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Mandi

I appreciate this article so much and wish more doctors--and patients--saw things this way! I have only recently been introduced to your blog and Facebook page, but, so far, I am impressed with your approaches and advice and what seems to be genuine care for your paying patients, as well as those of us only "meeting" you in these online spaces. Thank you for being real and for being humble and for sharing your wisdom with all of us!

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T. Mills

I love the way you place patients and their needs first. Thank you. functionalmedicinepatient.org

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Audrey

Hi Aviva! I love your forward thinking. I remember when I was a dietetic intern at a university hospital in NYC and would see doctors walking down the street in their white coat, ordering their lunch at a cafe across the street in their white coat, and sometimes even getting on a bus in it! I kept thinking- how is that good for the patient? I agree- it is very authoritative and I found difficulty working with some doctors who believe they are the medical authority over all things, including my specialty, nutrition. We should all be putting our brilliant minds together and WITH our patients!

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Rick

Thank you for your extended blog........ I once had an MD ask me: You know what MD means don't you? I requested his answer... He said MORE DRUGS... He was totally honest.. I refused to take the drugs prescribed, because the side effects would have been worse than my presenting symptoms.. He gave me a prescription of running 4 miles a day to combat my depression.. I flourished.. Unfortunately SOME doctors take on that "I KNOW EVERYTHING & you're a peon that knows nothing" Personally, I feel the Western world medical practice is all about removing symptoms & prescribing drugs vs creating HEALTH... REALISTICALLY, our misnamed HEALTHCARE system is really a DISEASE DRUG PRESCRIBING & SYMPTOM REMOVAL system that rarely gets to the CAUSE of the situation & HEALS.... I'm sorry, but I'm not a fan of MD's unless it's an "accident" and requires putting bodies back together... I've seen more than a few people go into the hospital sick, but ok and DIED there after getting mega drugs & getting weaker & weaker & TRUSTING the "experts" that seemed to be just experimenting on this person...... The so called "alternative healthcare" practitioners are realistically becoming the FIRST go to for more & more people who are concerned with HEALTH vs DISEASE control (thru drug prescriptions & just removing symptoms).... I commend YOU on your integrity. As far as "commanding" more respect by wearing a white lab coat..... Personally I find it DEMEANING because it's MY body & doctors are human too and DON'T know everything about everyone (but are too ego based to admit it)... If a practitioner can't relate to me as an EQUAL in a collaborative effort to help me achieve health, then they won't be seeing me in their office.... AND at 77 and not seeing any docs for YEARS ... doing my OWN self health care ... NATURAL things and NOT drugs.... I think I'm onto something.

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    Megan Liebmann

    Hi Rick, Thank you for your comment, your wisdom and your kind words! Warmly, Megan- Aviva Romm’s Executive Assistant and Online Nutrition Expert

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Selver Maric

When I reading this I have enormous faith in future of healthcare worldwide. Thank u.

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