The White Coat hierarchy

When I jokingly posted about the White Coat effect several weeks ago, I got a number of comments from other medical students about how their hospitals give out white coats (long and short) to everyone from physician assistants to nurses to dental students. So I started thinking about all of the white coat-clad people that I’ve seen wandering the halls of my own university hospital system, and there are actually quite a few. More, even, than I had the patience to include in my comic above.

White coats have long been a symbol of the medical profession, and surveys indicate that “easy recognition by patients and colleagues” is a chief reason that doctors and medical students choose to wear white coats. One thing that I don’t think I ever thought about or realized before I started medical school is that medicine is as much about putting on a show as it is about interpreting test results and handing out prescriptions. We perform mysterious physical exam maneuvers, speak using an unnecessarily complicated vocabulary, make small talk, smile, and yes, wear white coats, all (at least in part) to convince our patients (and sometimes our colleagues and superiors) of how smart or competent or compassionate or kind we are. We need to be able to make our patients trust us as much as we need to to actually be able to take care of them, and wearing white coats has traditionally been part of that equation. In fact, studies have shown that patients are more likely to trust physicians who wear white coats.

Of course, if the white coat inspires confidence, trust, and respect among patients, it’s no wonder that every health care professional under the sun (or anyone with any connection at all to health care) would want to wear one. But the white coat is as much a symbol of hierarchy as it is a symbol of competence. At most institutions, medical students like myself are required to wear short hip-length white coats, while residents and attendings wear long knee-length white coats. Some institutions have gone so far as to introduce different white coat styles/identifiers for med students, interns, residents, chief residents, attendings, and so on. As other health care professionals join the fray, the need to distinguish them from one another and from physicians at all levels of training, sometimes results in even more elaborate variations.

A friend of mine suggested that all the doctors and medical students should start wearing capes, just to see how quickly it would catch on in the rest of the hospital.

How I spend my time in the lab

The strange thing about medicine… You’d think that “prestige” would be tied to how well you care for patients, how few complications you have, or how many people would recommend your services to others. But really, like any other academic field, it’s all about the research. I have to say, until this past January, I never thought that I would be taking a year off to do research. I had always been a “straight-through” kind of girl (there’s probably a dirty joke in there somewhere), and by that I mean, I entered college right out of high school, entered med school right out of college, and didn’t take any breaks in between. Maybe it’s because everyone always calls it a “year off,” as if you’re taking a break from life so you can bum around on your ass for a year, but I always felt like I didn’t have the time. Fast forward the better part of a year, and now I’ve been lab-bound for almost 3 months. Go figure.

Whoever thought that a med student such as myself would be qualified to work in a basic science lab was probably mistaken. Of course, I could have opted for the Excel-monkey route and signed up to do clinical research, but sitting in a cubicle all day was exactly the kind of the work that I was trying to avoid by going to medical school. My “project” so far has felt like one long string of mistakes, set-backs, and dumb moments on my part. I was supposed to get around to animal studies, but so far, I’ve just been muddling my way through cell culture. But I’m learning, right? And what an expert I’ve become at the art of pipetting fluid volumes, small and large! Except that I really hope that I’ll pull it all together in time to have a thesis (and hopefully a few publications) by the end of this thing. And impress my professor somehow. Who happens to be chief of the-amazing-field-of-medicine-that-I-want-to-go-into. Who I’m pretty sure doesn’t even know my name at this point. Who I would really love to get a glowing recommendation letter from in a year’s time. I see her once a week at lab meeting, where my role is usually to say an apologetic sentence or two about how I’m still failing at doing the thing I thought I would have had done by now. She intimidates me (though really, I’ve gotten every indication that she is, in fact, actually very nice).

Anyway, back to what I talking about before. Lab work is quite a change of pace from 3rd year. A few months ago, I was regularly working 60-80 hour weeks. Now, I think 30 hours would be a generous estimate. In theory, I can waltz in whenever I want and leave whenever my work for the day is finished. And my “work for the day” usually takes no more than 3-4 hours. Apparently you can’t prod cells into growing any faster than they want to. I’m enjoying the break. Except for the part where, probably out of residual 3rd year guilt, I feel the need to stay and sit in my office after my “work” is done because, really, 1:00pm is much to early to go home. Of course, I rarely do anything more useful than mindlessly browsing the internet when I do this. But I’m there, so it should count for something, dammit!

So far, I’ve realized two things about myself. The first is that I’d rather work the long hours, as long as I’m not sitting around bored for any length of time. The second is that I never would have made it in grad school. By the way, I never realized how true PhD Comics were until now.

Watching TV…

I have a confession to make. Back when I was in college, I was big fan of medical dramas. I watched everything from House to Grey’s Anatomy to Scrubs, and I tuned in faithfully every week. I knew that these shows probably didn’t reflect the reality of working in a hospital, and I had some vague sense that the medicine was probably crap, but I didn’t really know any better. I enjoyed the (sometimes trashy) drama, the (sometimes half-baked) ethical dilemmas, and the (usually exaggerated) characters. It was all good fun, and with my growing interest in medicine as a career, I was naturally drawn to them.

For a while, during 1st and 2nd year, I continued to watch my favorites. It was even fun to play along with House, for example, and try to guess the diagnosis. It wasn’t until about half way through my 2nd year of medical school that I began to understand enough of the medicine for the utter wrong-ness of these kinds of shows to start grating on my nerves. At first, it was just the minor gripe here or there. Soon, I was ranting almost constantly throughout each episode. Finally, I just couldn’t take it anymore, and I had to categorically ban myself from any further medical drama consumption. But it didn’t stop there. Apparently, fake medicine pervades cop dramas, action flicks, war stories, and just about every other genre out there. Oh med school, how you’ve ruined a perfectly good way to waste my time!

The “deceptive” income of physicians

One perennial topic of profuse internet discussion, ranting, and general circle-jerking among medical students, American medical students in particular, is the idea that doctors’ incomes are “deceptively” high, and that really, when you take all the cost and effort of training into account, physicians don’t really make any more money than [insert some other “humbler” profession of your choice]. This is a topic that pervaded blogs and forums back when I was a bright-eyed pre-med seeking advice for my med school applications, and it continues to be a popularly repeated topic now, as I near graduation. Most recently, this article has been making the rounds on reddit, and to be honest, I’m really sick of it. Yes, medical education is expensive. Yes, the training is long. Yes, you have to work hard. And no, you probably shouldn’t decide to go into medicine if money is your only objective. And I do think that we probably deserve the high salaries that we’ll eventually get. But what’s this need to compare ourselves to everyone from high school teachers to nurses in order to “prove” how much “worse” we have it?

We were the ones who, of our own free will, decided to put ourselves through this. Because, after careful consideration, we thought that it would be worth it. Few of us came into this blind. Most of us could have succeeded in any number of other potential professions. And if we really thought that it would have been better to become high school teachers, dentists, and nurses, we would have picked a different path. Can we really not just be happy with our career choices without trying to convince everyone else that we’re all a bunch of self-sacrificing martyrs who have dedicated our lives to the thankless service of humanity?

I think the real reason that these kinds of discussions keep happening is that we’re afraid. With all the recent talk about runaway healthcare costs and “bending the curve,” many members of the lay public have looked at doctors’ salaries as a potential place cut costs. And so we’ve become defensive. We’re afraid that by the end of our grueling training (and I do agree, as anyone who has done 24-hour call or worked an 80+-hour week will, that the training is grueling), after we’ve all worked so hard to be worth what we thought we’d be worth, that by then, our salaries will have been cut to pieces and the journey wouldn’t have been worth it at all anymore. So we make ridiculous claims about how we should have all just become high school teachers instead (since no one could ever accuse a humble high school teacher of making too much money), not because we actually believe it, but because we want to convince everyone else to sympathize with us. And somewhere, deep down, with the smallest tinge of guilt (because most of us did go into medicine, at least in part, because we had some selfless notion of wanting to “help people”), maybe we do wonder if doctors might just be a little tiny bit overpaid after all. But as soon as that thought surfaces, we drown it again in another wave of facts and figures and comparisons.

The White Coat effect

Last year, while I was doing my clinical rotations, I got used to being able, essentially, to go anywhere and do anything in the hospitals. This included using physician computers, accessing restricted areas, boarding staff elevators, and feeling free to ask staff members for the door codes to physician workrooms and lounges. Security guards cheerfully waved me through metal detectors with a “C’mon in, Doc!” despite the fact that my pockets were bulging with metal equipment, and nurses held the doors to medical supply closets open for me. And this is with my short med student white coat– few lay people seem to know the difference between the short white coat that medical students wear and the long white coats that the MDs wear.

I’m taking a year off to do research this year. I’m about 2 months in now. Among other things, doing a research year means that I’m spending a great deal of time hanging around the medical campus without my traditional medical student get-up on. More specifically, it means I’m leaving my white coat at home most of the time. And I’ve noticed the difference. I look young for my age, and I often get mistaken for being college-age, or even, on occasion, high school-age. The white coat seems to give me an air of importance/authority that I otherwise don’t seem to have. It could be that I just feel a little more self-conscious without it, but I swear that I’ve been getting just a few more questioning glances and “Can I help you?”s and just a few fewer welcoming smiles and “Have a nice day!”s. It’s odd how one little piece of clothing can make all the difference in how people look at you.