The White Coat Ceremony often marks the beginning of medical school. I remember standing on stage before a crowd of families, friends, distinguished physicians, and professors as I was ceremoniously helped into my white coat by one of the deans. I remember that unexpected feeling of transformation of wearing the white coat for the first time. It was an uneasy feeling of power balanced by trepidation derived from foresight into the responsibility required for supporting and treating individuals compassionately in their most vulnerable times. However, these emotions were evanescent over the next two years of school as I immersed myself in such subjects as the anatomical nerves of the brachial plexus and the biochemical pathways of energy metabolism.
Early one morning at the beginning of my third year, I was presenting a case to my team of fellow classmates, an intern, a resident, and an attending physician during morning rounds. My glowing white coat, immaculately pressed, was evidence of my recent introduction into the hospital setting. I had meticulously prepared my presentation, notes scribbled across the top of a stack of papers on my clipboard. “Mr. H is a 45-year-old male with a history of hepatocellular carcinoma secondary to alcoholic cirrhosis who now presents with episodic vomiting, abdominal pain, and distention. A CT scan yesterday shows metastatic cancer that is encasing the portal vein. He is developing renal failure as evidenced by an increase in his BUN and creatinine,” I sounded off.
Dr. Z, the attending physician, nodded in restrained approval. He led us, his troupe of residents and medical students, into the patient's room to the bedside. His long, duller white coat with patches of gray here and there like badges of honor caught a draft of air and trailed behind him. The partially closed blinds in the room obscured the initial rays of the sunrise painting the sky purple-red. Mr. H, emaciated from liver disease, lay still in a fetal position; his ruffled long salt-and-pepper hair obscured a jaundiced complexion. In the dim light, colorful tattoos on his extremities came to life like a cartoon. The action paused seconds later when Mr. H had achieved a completely supine position, ready for the all too familiar physical exam routines. His short and skinny, 81-year-old father, hard of hearing, sat hunched in the corner half asleep, eyes blinking open slightly, and trailing us as we approached his infirm son. A walker stood next to his chair.
A few words of greeting and introduction were quickly replaced by medical jargon directed at the team. Dr. Z lifted Mr. H's arms and held out his hands, which instantaneously began to flap uncontrollably, as if they were tapping an invisible drum to the rhythm of the Sirens' song. Fascinated, Dr. Z proclaimed, “This is classic ‘asterixis’ and is one of the many signs of liver failure.”
Asterixis … I scribbled in my notes, not sure if I had even spelled it correctly.
Dr. Z exposed Mr. H's abdomen with little resistance, revealing what looked like serpiginous shapes beneath the skin. “Caput medusae, another sign of liver failure.”
Mr. H dutifully laid in bed in silence, allowing the team to take turns palpating, auscultating, and percussing. The entire process was quick and formal; neither Mr. H nor his father asked any questions. “You are doing great,” Dr. Z exclaimed to Mr. H before leading us out of the room. Everyone knew the prognosis was grim; a couple more days, possibly weeks, were all that were left in this young man's life.
“We have done all that is possible for Mr. H,” Dr. Z said as he patted me on the shoulder. “He is receiving the best care, partly thanks to you.”
But there was no time to reflect, only more patients to see. There was Mrs. S, for example, the 77-year-old lady with a chronic obstructive pulmonary disease exacerbated by years of chronic smoking, and Mr. P, a 43-year-old, HIV-positive male with a fever and low blood count. Each encounter was meticulous and methodical. Few words were exchanged with the patient or family. All medical judgments made appeared appropriate, lab work ordered, and paper work completed.
Later that evening I was able to process all that had transpired. In the chaos of a busy hospital service, we had completely glossed over the human aspect of medicine. I thought about Dr. Z's compliments about caring for Mr. H. In reality, he received mediocre care at best. That moment, the realization that we had barely interacted with Mr. H, his father, or any other patient on our service was poignantly heartbreaking and ignited that peculiar combined feeling of power and trepidation I first felt at the White Coat Ceremony.
We don our white coats to become physicians. Yet over time, the white coat, a formal garment, becomes a representation of the barrier that separates the technical from the humanistic aspects of medicine. The positive demeanor, that gentle deliberate touch, that lingering smile, and expression of warmth which are equally important in providing hope and support for the medically crippled to lean on are lost through the stresses, time constraints, and technical aspects of medicine.
The next morning, I found Mr. H sitting at the edge of his bed staring out the window at the bright morning sun. His father had left the night before, so I decided to sit down and keep him company for a bit of time. I soon learned that Mr. H had lost his wife and three kids 12 years ago to a house fire started from an electrical malfunction. Alcohol was his maladaptive way to assuage the pain and loss he felt. “I'm looking forward to seeing them soon, you know,” he whispered as his eyes remained transfixed at the bright city landscape in the distance. “By the way, you aren't wearing your white coat today.”
“I'm trying something different for a change,” I replied.
“I like the new look.”
The Arnold P. Gold Foundation Humanism in Medicine Essay Contest
The Arnold P. Gold Foundation is a not-for-profit organization founded in 1988 to nurture and sustain the time-honored tradition of the compassionate physician. Today, students, residents, and faculty participate in at least one Gold Foundation program at over 93% of our nation's medical schools and at schools abroad. Its programs and projects are derived from the beliefs that compassion and respect are essential to the practice of medicine and enhance the healing process; the habits of humanistic care can and should be taught; and medical role-model and mentor practitioners who embody humanistic values deserve support and recognition.
In 1999, the Gold Foundation instituted the annual Humanism in Medicine Essay Contest as a way to encourage medical students to reflect on their experiences in writing. Since the contest's beginning, the foundation has received close to 2,000 essays from students at more than 125 schools of allopathic and osteopathic medicine.
Contestants for the 2010 Humanism in Medicine Essay Contest were asked to address the following prompt: “Describe a barrier a physician might face to practicing humanistic patient care. How might this be overcome and what can be learned in the process?” Winning essays and honorable mentions were selected by a distinguished panel of judges. For the ninth year in a row, Academic Medicine is pleased to publish the winning essays from the contest.
Winning essays are also published on the Gold Foundation's Web site (www.humanism-in-medicine.org) and in the foundation's DOC newsletter. For further information, please call The Arnold P. Gold Foundation at (201) 567-7999 or e-mail: [email protected].