white coats are for medical students

White coats mark a right of passage in medicine

In just a few weeks, my classmates and I will participate in what has become a medical right of passage: the white coat ceremony.  The white coat ceremony commemorates the formal presentation and cloaking of the white lab coat for medical students.

What is the meaning of the white coat, and how did it earn its emblematic status in the health professions?  In this first part of two, I’ll be discussing what I learned about its the white coat ceremony’s history and meaning.  After our own white coat ceremony on 12/10/2010, I’ll post part 2, in which we’ll share our personal experiences with the event.

Before the White Coat Ceremony

  • Black coats were originally used to dissect cadavers, as a sign of respect for the dead.  White later became the preferred color because it symbolized cleanliness, purity, and righteousness, did not fade when washed at high (germ-killing) temperatures, and any soiling was easily noticed.
  • White coats have been the most prominent symbol of the physician since the development of aseptic surgery in the U.S. in about 1889.  Surgeons at Massachusetts General Hospital can be seen wearing them in photographs of surgeries.  They were worn in an effort to prevent patients and physicians from contaminating each other.  Ironically, the doctors in these photos aren’t wearing gloves or masks, as they were not yet accepted in the field.
  • By the early 20th century, health care had moved from patients’ homes into hospitals.  Limited infection control measures, unfamiliar surroundings, and unproven treatments often made the public reluctant to access the care that was available to them in hospitals.  To enhance its credibility and reassure the public that hospitals and doctors were indeed safe, the medical profession began to associate itself with science, a field that had begun to earn the public’s respect and trust.  Science had built the Panama Canal, invented the telephone, and made possible the first human flight.  Linking medicine with science began to soften the pubic distrust.  By 1920, the white coat had become a powerful and iconic symbol of the physician as medical scientist.

    before white coat ceremonies, the public trusted scientists more than doctors.

    During the early 20th century, the public trusted scientists more than doctors.

  • White coats have plenty of critics – chief among them, some doctors.  Most surveys of doctors show that they would prefer not to wear them because they are hot, expensive to launder, and can intimidate patients.  Unfortunately for these doctors, studies of patients usually find that they prefer their physician to wear one.
  • ” White Coat Hypertension” refers to the well documented observation that 15-30% of patients are mildly hypertensive while in the clinical setting, but show no elevation in blood pressure in other settings.  The cause has not been proven, but it is thought to be related to the anxiety that patients feel when in clinical settings.
  • Some  feel that the use of white coats by clinicians perpetuates an unhealthy power dynamic that invites the patient to idealize the clinician and devalue their own knowledge.  There have been recent movements to end the use of white coats in medicine because of the power it has come to represent, and to reduce the spread of infection that many assume occurs when clinicians wear the same coat to see different patients.  To curb infection that may be spread this way, some nations (notably Great Britain) have switched to short-sleeved coats.  Ireland has banned them altogether, along with jewelry and neck ties.  The American Medical Association considered banning them in 2009, but stopped because of a “lack of scientific evidence.”
  • For years, doctors wore white coats of differing lengths, according to personal taste and the traditions of the hospitals in which they worked. There are no hard and fast rules, but the trend is to associate the shorter, hip-length coats with those in training.  For most, the longer coat is seen as more fashionable, and therefore its use is only earned with time.  At some hospitals, such as Massachusetts General, all physicians wear the short coat to symbolize their status as lifelong learners.  In other hospital systems, coat length is a very accurate indicator of medical status — the longer the coat, the higher the status and experience of its wearer.

The White Coat Ceremony Today

  • a modern white coat ceremony

    A modern medical right of passage

    The white coat ceremony is a recent development, originating at Columbia University’s College of Physicians and Surgeons in 1993, and has since expanded to other health professions, including physician assistants and pharmacists, and schools of medicine outside the U.S.  The white coat ceremony was developed by Arnold P. Gold, M.D., who sought to bring a humanistic focus to medicine.  According to Dr. Gold, “A physician’s responsibility is not only to take care of patients, but also to care for patients.”

  • Because of the power dynamic implied by the white coat, some schools have switched from a white coat ceremony to a stethoscope ceremony.  Instead of presenting a coat to the student, a stethoscope is placed on the shoulders of the novitiate.  The act is meant to symbolize the gift of something that will connect doctor and patient, rather than something that will separate them.
  • Today the white coat ceremony has become a common tradition in most medical and physician assistant schools, as well as other schools of advanced medical training.  There are many variations, but perhaps the most common is to hold the white coat ceremony when the student begins working with patients in hospitals, since this is usually a departure from the heavily text-and-lecture-dependent early training to more practical clinical training.