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.