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Unintentional Subterfuge

Myers, Kimberly R. PhD, MA; Volpe, Rebecca L. PhD

doi: 10.1097/SLA.0000000000001925
Surgical Perspectives

Department of Humanities, Penn State College of Medicine, Hershey, PA.

Reprints: Kimberly R. Myers, PhD, MA, Humanities Department, 500 University Drive, H134, Hershey, PA 17033. E-mail: krm16@psu.edu.

No funding was received for any part of this Perspectives piece.

The authors report no conflicts of interest.

“the apparel oft proclaims the man…”

Shakespeare, Hamlet

“How long will it be before I can play the cello again?” The patient, prepped for bilateral mastectomy and reconstruction, lay on the gurney and looked to me (KM) expectantly. I was dressed in green scrubs, ready for the operating room, but I had no idea how to respond. After all, I was merely a visitor that morning—a layperson with no medical training.

I had first met Mrs. S when I stopped by with the breast and plastic surgeons who had come to initial the surgical site. The surgical oncologist introduced me—“my colleague, a literature professor who teaches medical students, and also a patient of mine”—and asked if it would be okay for me to observe her surgery. He explained that I had undergone the same procedure 6 months earlier and now wanted to see the particulars. She readily agreed and smiled warmly, if wanly, at me. As the surgeons asked some final questions, she continued to make eye contact with all 3 of us who were dressed in scrubs.

Like most people, Mrs. S was at her most vulnerable as she lay in our hospital awaiting surgery. Serious illness and the stress that accompanies it are inherently disorienting, and confusing visual cues compound the problem. In moments of crisis, the only important question is “Who can help me?,” and patients literally look for an answer not so much in the faces but in the attire of those bustling around them.

People understand our professional roles in part by what we wear. Uniforms are often helpful—the orange shirts in Home Depot, reflective neon yellow for road crews—but when the same uniform is worn by people who have very different roles in the high-stakes environment of a hospital, they can be misleading and even dangerous. The white coat, even more so than scrubs, is a powerful artifact that confers the legitimacy of doctoring onto the wearer, whether the wearer is a physician or not.1 To what extent, then, do we unwittingly undermine patient autonomy simply by dressing in a certain way? In the interest of patient empowerment, should we ask ourselves who should be required to wear these uniforms and who should be discouraged or even forbidden to wear them?

“Hi, I’m Dr. G. I’m the clinical ethicist,” said the man in the long white coat as he walked into the patient's room. I (RV) followed behind, a trainee on an away rotation. “I’d like to chat with you about your son's values and preferences – what he was like as a person before all this,” he told the parents sitting next to their intubated son.

“Ok Doc” said Dad. “But first can you tell us when he’ll get that tube out?”

“That's hard to say,” said Dr. G. “It's going to depend upon his course over the next couple of days.”

Dr. G reoriented the discussion toward the patient's wishes and talked with the family about how their role was to represent what the patient would choose, if he were able to speak for himself.

As we were leaving, Dad said, “Thanks Doc.”

We walked out of the room—Dr. G leading, me behind—and I wondered whether those parents knew that Dr. G could not have known the answer to their question about when the tube would come out. Despite his long white coat, pockets brimming with the usual pocket guides, the inscription of his name “Dr. G” on his coat, and the way he seemed to introduce himself as a physician, Dr. G is not a medical doctor. He has a doctorate—a learned and experienced person, yes; a medical doctor, no.

To be sure, the way we dress is tied to issues of both professionalism and practicality. Consider, for instance, lab technicians and basic scientists for whom white coats serve the practical purpose of keeping clothes clean. So, too, for medical students, even though their white coats confound the issue even further. Medical students are identified—at least by those who know medical culture—by short white coats. But it is doubtful that the average patient or family member understands this distinction—at least until after they have been in the hospital long enough to observe who watches in silence and who makes the decisions when the team rounds. Trying to navigate this complex web of visual cues can heighten confusion and stress for people who are sick.

As part of the current push for greater transparency in health care, institutions are working to communicate more clearly about roles and procedures. For instance, best practices increasingly include requiring every health care professional who encounters a patient to verify the patient's identity, to identify herself and the role she will play in the patient's care, and to request permission for each intervention and medication.2 We adopt these systems practices in order to enhance patient safety and patient satisfaction and to empower patients and their families by providing the understanding and the tools they need to exercise autonomy. These overt efforts are undermined by the tacit assumptions people make about who we are when they see how we dress.

Impressed by the significance of this conundrum, some institutions are taking steps to ameliorate the problem. For example, the Mayo Clinic has established a highly specific “Dress and Decorum Policy”3 and posts in patient-care areas a “legend” to map the terrain of professional dress in order to alert patients to the identities and roles of the potentially dozens of practitioners who will care for them. Even such commendable measures are subverted, however, by the degree to which patients and families are both anxious and disoriented in medical settings.

As the surgeons were leaving to scrub in, Mrs. S asked if I (KM) would stay and talk with her. I readily agreed, knowing that almost any distraction before surgery is welcome. Perhaps my presence, especially as one who had healed from the surgery she was about to undergo, would alleviate some of her anxiety. She looked up at me before I could sit beside her. “How long will it be before I can play the cello again?” she asked. I explained that she would need to ask Dr. K and reminded her that I knew only what I had experienced as a patient. She nodded okay and went on to ask about drainage tubes—how long would they remain in place—and pain—what medicine would she be prescribed and how long would she need to take it. I answered what I could, careful to frame everything as “my personal experience,” and encouraged her to ask Dr. K the rest after surgery. After about 5 minutes of my mostly listening to her concerns, Mrs. S. repeated, “How long will it be before I can play the cello again?” Although I had just reiterated several times that I was merely a former patient with no medical training, what I was wearing suggested otherwise. My scrubs spoke louder than my words.

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REFERENCES

1. Fiol CM. Rafaeli A, Pratt M. Stuff matters: artifacts, identifies, and legitimacy in the US medical profession. Artifacts and Organizations. Mahwah, NJ: Lawrence Erlbaum Associates; 2006. 241–257.
2. WHO. Patient Identification: Patient Safety Solutions. WHO Collaborating Centre for Patient Safety Solutions, 2007. Available at: http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf. Accessed November 20, 2015.
3. Mayo Clinic Health System. Dress and Decorum Policy, 2012. Available at: http://stmedia.startribune.com/documents/ProfessionalDressPolicy.pdf. Accessed January 26, 2016.
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