When you see a white coat, what is your first thought? To you as a medical student you might think I can't wait 'til I get one of those! The white coat signifies reaching your goal to be a physician. A long white coat means that you have become faculty! Oh my! I'm not going to talk about what Freud would say about the long coat vs. the short coat.
When your patient sees a white coat, what is their first thought? It might cause enough anxiety to raise their blood pressure, causing the white coat syndrome. In my specialty, psychiatry, it is the men in the white coats who are coming to take you away!
So, why do physicians wear white coats? When I was asked to give this talk, it occurred to me that I had no idea where the white coats came from. As I first started reading about it, the answer appeared to be that doctors began wearing white laboratory coats to appear more scientific.
Doctors in the 1800s were struggling to establish credibility in the eyes of the public. There were not many effective treatments available and often the doctor's role was one of informing the patient and family what condition the patient suffered from and what the likely course of illness would be. They provided assistance when possible and comfort as they could, but many times they were limited in what they could do and sometimes their interventions made things even worse. But, as I read more about it, a much more interesting story emerged.
Until the late 1800s, physicians wore black clothing, which was pretty much what all the men wore in those days. They cared for their patients and performed surgery in the same type of clothes they wore out on the streets. Surgeons in those days wore dark surgical frock coats. A dirty surgical coat was seen as a sign of the surgeon's experience. They allowed blood and pus to accumulate on their clothing and would not wash or change coats day to day or from dissecting lab to operating theater. They thought the emission of pus from a wound was a good sign that the dead tissue was being carried out of the wound. The smell that accompanied their dirty frock coats was referred to as "that good old surgical smell."
On your program there is a painting by Thomas Eakins entitled The Gross Clinic with all the surgeons and students wearing dark clothes. Gross was not a description of how bad it smelled or even what the patient's mother is thinking over behind the surgeon as she sees her son operated on.
Rather, Samuel D. Gross was the name of the surgeon standing there, bloody scalpel in bare hand, holding forth to the operating theater full of students watching with rapt attention. Those are your professional forebears from 1875. Dr. Gross was the Chair of Surgery at the Jefferson Medical College in Philadelphia and one of the most eminent surgeons in this country. The patient had osteomyelitis of his femur. For the parents, that is a bacterial infection in his thigh bone and is very difficult to cure, even in these days of antibiotics.
In England, a quiet revolution had been under way for about ten years before this painting. A young surgeon named Joseph Lister read the writings of Louis Pasteur describing how bacteria cause putrefaction of wine and beer.
Lister had the realization that bacteria could also cause putrefaction in surgical wounds. He began using a solution of carbolic acid to sterilize his surgical equipment, to wash his hands prior to operating and even to spray on the wound itself. He studied the rates of postoperative infections and survival and published a series of five papers in Lancet from March to July of 1867. His fame spread and surgeons in Britain and Europe began adopting his techniques that saved lives and reduced post surgical infections.
His approach was not so widely accepted in the US. In fact, Dr. Gross invited Dr. Lister to come to the United States to lecture in order to refute his claims about the antiseptic technique.
Lister came to present at the International Medical Congress which was held in Philadelphia in 1876. The congress met as part of the Centennial Anniversary of the signing of the Declaration of Independence.
Lister came and gave a three hour discourse on his methods and outcomes. The American audience was not impressed. The president of the International Congress was quoted as saying, "Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called (antiseptic) treatment of Professor Lister."
There was one enterprising young man who attended that lecture and saw an opportunity. Robert Wood Johnson of the future company Johnson and Johnson decided to develop and mass produce sterile sponges and dressings and other surgical supplies based on what he heard Lister present that day. He later published a book titled Modern Methods of Antiseptic Wound Treatment which was the first handbook of sterile technique published in this county. Of course in the spirit of free enterprise there was a complete listing of Johnson and Johnson products in the back of the book.
The American surgical establishment persisted in their ways for the next several years until their beliefs were rocked by a national tragedy, the assassination of a president.
James Garfield was elected president in 1880. He was considered by many to be the finest orator of his age. He was a progressive man, advocating for the end of the patronage system in government and for the full equality of slaves freed by the civil war.
Only 4 months after he took office, the president was shot in the back by a delusional assassin. The bullet fractured the 11th and 12th ribs, fractured a vertebra without damaging the spine and came to rest deep inside the left side of his back.
Unfortunately for the President and for the nation, the surgical team who cared for him had not adopted Lister's antiseptic technique. Within an hour of the shot, they were probing the wound with unwashed fingers and silver probes trying to find the bullet to remove it. They introduced bacteria into the wound with every procedure. The President lived for 80 days after the shooting and finally died of overwhelming infection. Autopsy revealed multiple pus-filled cavities. The presiding surgeon, Willard Bliss, refused to accept the findings of the autopsy, insisting that the President died of a broken back. Several prominent physicians of the day believed that the medical care he received killed the president, rather than the gunshot wound.
The public outcry following Garfield's death gave new credence to young physicians who had been advocating for Lister's antiseptic technique. As part of this movement toward the antiseptic approach, surgeons began wearing white surgical garb. The second painting by Eakins, The Agnew Clinic, was painted in 1889, 14 years after The Gross Clinic. The distinguished gentleman to the left, Dr. Hayes Agnew, was a professor of surgery at the University of Pennsylvania. The sterile instruments are stored in a container you can see between Dr. Agnew and the surgical team. In an interesting twist of fate, Dr. Agnew was one of the surgeons assisting in the care of President Garfield after he was shot.
Following Garfield's death and the public outcry about his medical care the antiseptic technique became widely accepted. In 1888, Johnson and Johnson published Modern Methods of Antiseptic Wound Treatment, which helped revolutionize wound care in this country. Two authors of the book: Dr. Hayes Agnew and Samuel W. Gross, son of Samuel D. Gross of the Gross Clinic painting.
So, what do we learn from this brief history?
Lister's research bridged laboratory and clinical science. He took the findings from Pasteur's basic research and applied them in the surgical suite to the benefit of countless patients. His studies helped begin a more scientifically based era of medicine. As physicians developed more scientifically based treatments the white coat became a symbol of our profession. But we must keep in mind both the light and the dark sides of that symbol. The same drive for excellence that has led to you sitting here, beginning your medical school education, can lead to a false sense of knowing more than you really do. It can lead you to feel superior. It can lead to a mind closed to new information. Dr. Gross was one of the leading surgeons of his time and was responsible for many surgical innovations, but he was unable to see past his own beliefs about the truth and so was unable to accept Lister's findings. So, the first lesson is to remain humble in your knowledge. Remain truly a scientist, always willing to test your hypotheses and holding no truth to be sacred.
A second lesson is that science guides us, but does not rule us. Objectivity and reliance on science can be carried too far. Our randomized, double blinded, placebo controlled studies can't cover all of the situations you see in a clinical practice. You will always have to make judgments about the individual who is sitting in front of you. You have to be comfortable making decisions based on probability rather than certainty.
When we say the word antiseptic, what do we think of? For those of us in the medical profession, we think of cleanliness and decreased infection rates. In our general culture antiseptic also has the negative connotations of being sterile, unfeeling, cold, analytical, and aloof. We can become so enamored of our scientific knowledge; so focused on the mechanisms of disease that we lose sight of the human beings we are treating. So strong is the pull of scientific fact and desire for certainty that it is almost impossible for this not to happen.
Often, the emotional side of the work we do is painful and we retreat behind our white coats of scientific certainty. Patients are reduced to their medical conditions so you don't have to feel their suffering. You find yourself thinking of the MI in the heart tower or the ALS on neurology. So, we must act with science as our foundation, but remember that in its practice, medicine is an art.
Which leads me to the third lesson, which is about compassion. If you get to really know your patients as people, you will be have more compassion for them. If you think about how you would talk about one of your family members in the hospital, you would never refer to them by their diagnosis. It wouldn't even occur to you to do so.
I imagine that you are all compassionate individuals and that compassion was one of your motivations for entering medical school. But at this point, yours is an abstract, untested compassion. Patients sometimes are angry, frightened, drunk, high, belligerent, and physically aggressive. They may curse you, spit on you, walk out on you, throw up on you and perhaps worst of all, refuse to follow your recommendations.
Medical training is exhausting so you often have little emotional reserve yourself. Yet, you are expected to be friendly and caring at all times. In the worst cases we let our emotional reactions cloud our judgment and affect our care of those patients.
Sarcastic comments are made about the patient who came in to the emergency department with a suicide attempt or about the massively obese woman who is hypertensive and diabetic and who just won't lose weight. Or the opiate addict who comes in asking for pain medications.
As a student you will hear residents and attendings make humorous, sarcastic and sometimes cruel comments about patients. Every year at the beginning of the year we hear our third year students in Asheville talk with shock about how patients are talked about in rounds at the hospital. Now granted, they start the year on surgery and Ob-Gyn, so that biases the sample, but we all have talked that way at some point in our training or later when we are stressed or frustrated.
It is much better to channel your feelings into sarcasm than to let it effect your care, but I encourage you to see this as a phase you will go through but grow out of. You grow out of it by increasing your ability to feel compassion.
In my experience, compassion is perhaps one of the more difficult skills to learn. Some people are easy to feel compassion for, but feeling compassion for your difficult patients often does not come easily. I am convinced that compassion is a skill that can be developed along with the skills of taking a history and performing a physical exam or a mental status exam.
When you find yourself angry or resentful with a patient and wanting to make a sarcastic remark about someone, acknowledge that within yourself. Practice not saying anything about a patient that you wouldn't say straight to their face. Learn as much about them as you can within the limits of your time with them. One thing I've noticed among the senior teachers of the medical students is that they are much less likely to engage in this sort of banter. My experience is that after you get to know patients over several years and understand the reasons behind their behaviors you feel much less judgmental toward them. Once you have had that experience with a few hundred patients you reach a point where you are less judgmental even from the beginning of your relationship with a new patient.
So, when you put on your white coat, let it remind you to be humble in your knowledge; scientific but artful; and to be compassionate toward even your most difficult patients.
I wish all of you the best in moving forward with your careers in this wonderful, amazing profession that you have chosen and look forward to meeting some of you in Asheville in another couple of years.
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