John Livingston News Opinions / Op-eds

The White Coat

I have noticed over the past 12 years that a very small number of physicians have posed with politicians in their “white coats”. There are over 3000 physicians practicing in Idaho today and when a small group 5, pose in the capital building in their white coats the general public may believe that this small group is actually speaking for the medical profession as a whole.

The real truth is that the majority of the 3000 physicians in Idaho are working so hard seeing patients that they don’t have time to take off from their practices to testify or demonstrate at the capital. Physicians by nature are not politically active. Most believe that the duty to patients is a responsibility to patients—particularly sick patients, and not to a political cause?

In 2009 I was in Washington DC representing the American College of Surgeons on their Executive Committee when I was asked if I wanted to meet President Obama. I said of course I did, but when I got to the White House, I was told that there was a white coat waiting for me to pose in the Rose Garden with the President. I and the majority of my colleagues walked out of the ceremony (not reported by the press) prior to its even starting. We refused to allow a symbol of the medical profession to be used for political purposes.

I believe that many of the people posing in their white lab coats really don’t understand the history of the coat. They may also not understand that in allowing politicians to leverage a symbol of their profession, they are, in fact, demeaning the values that are represented by that symbol.

Interestingly, physicians did not start wearing white coats until the late 1890s in our country. There are some specialties that do not wear the coat because they believe that the authoritative connotation of that symbol may interfere with the doctor-patient interaction—pediatricians seldom wear a white lab coat.

For most medical students at the mid-portion of their 1st year of medical school, they participate in a ceremony where they 1st put on the white coat. Usually, a family member-spouse or parent, or a respected teacher or mentor is given the honor of helping that student 1st put on the coat. It is believed in our country that the white coat—in its various styles had its origins at John Hopkins with Dr. William Osler the “father of Internal Medicine”. Medical students at Hopkins wore short white coats that looked more like a sport coat. Residents and Interns wore coats that extended to the mid-thigh. Staff and attending physicians wore long coats that extended to mid-calf. So in addition to identifying the wearer of the coat as a caregiver, it also defined their status and level of authority and responsibility.

Prior to the establishment of John’s Hopkins caregivers wore black uniforms. Surgeons and physicians wore suites. There is a very famous painting called “The Gross Clinic” about an amputation done at the University of Pennsylvania Hospital where all the surgeons in the operating room are wearing black formal attire. Catholic Sisters wore black habits attending to patients on the “Alms wards” until around 1900.

During my own “white coat ceremony” over 40 years ago Dr. Hutch Williams at Ohio State warned the 1st year medical students that the white coat was a symbol of the fidelity of the clinician to the patient. In his talk, he specifically pointed out that lawyers, bankers, and politicians don’t wear white coats. He warned us to always be a doctor when you wear the coat. You were not to wear the coat when going to church or working in a business office. You were not to wear the coat for example when attending a hospital board meeting, because your responsibility at that meeting was too many patients in your community not to “your patient’. You were not functioning as a doctor clinician in those situations. At Academic ceremonies like commencements doctors wear academic garb, not white lab coats—they aren’t serving patients at academic processions. I would argue that when a doctor participates in the political process, they should not wear a white lab coat.

I have testified on numerous occasions before legislators. I sit on the State Health Insurance Exchange Board. I never wear my white lab coat except in a clinical setting. So let’s remember when a small group of physicians at the capital present themselves publicly outside a clinical patient care setting, we need to understand two very important things. They are an extreme minority—around 1/1000 physicians—the others are serving patients.

We also need to understand that maybe they are in fact representing a special interest group like the IMA or the IHA or a hospital where they are employed. No matter what, in my opinion, they are trying to leverage their special position as a caregiver for political and economic purposes. Next thing you know we will see hospital administrators, CFOs, and the CEO heads of the IMA/IHA parading around the capital in white lab coats trying to score political points. It’s not illegal, anyone can wear a white lab coat. There is, in fact, an irony here.

The Latin word for white and pure is candidos from which the words candor and candidate come from. In ancient Rome “candidate” legislators wore white togas symbolizing candor and truth. We probably won’t be able to get our legislators to wear white togas and tell the truth (maybe we could get IACI and some other lobbyists to chip in) or better yet arrange for a toga party at Sun Valley to be paid for by the lobbyists with any extra money being put in a “scholarship” fund or used to build new office space or our representatives.

What I have learned in the last 4 years of the debate about Medicaid and Medicaid Expansion is that most political rhetoric purposefully tries to provoke emotion, when good political and economic policy requires empiric logic and discernment. In the end, I guess if you wear a white lab coat and support Medicaid Expansion you are more caring and empathetic than someone like me who doesn’t try to leverage a privilege and exploit those on the margin.

I have always believed that it is an obligation for all of us individually to take care of those on the margins with chronic diseases who cannot take care of themselves through no fault of their own, but when we also take on the burden of subsidizing healthy people we will limit access for those currently in need and who are in the traditional Medicaid population. Isn’t it interesting that those most in need who Medicaid was designed to help 1st, never testified before our legislature? They are the ones who will be hurt by expansion.

Where are the white coats looking after those patients? — Busy at work in the clinics and hospitals not lobbying.

Maybe next year the IMA/IHA can buy white coats for naive physicians that under their name and MD will have a monogrammed lobbyist’s sticker on it—I have some designs in mind for those interested.

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