Dean's Newsletter

Archive of previous newsletters

Two Perspectives on the White Coat

August 25 , 2006

At the end of orientation week for new medical students, the School of Medicine and Dentistry conducts a White Coat Ceremony, in which each first-year medical student dons his or her white coat for the first time, symbolizing their entry into the profession of Medicine.

This year, our White Coat Ceremony on August 18, 2006 was particularly special for two reasons, which will serve as the subjects of this two-part newsletter.

First, this event was named to Robert and Lillian Brent White Coat Ceremony, in honor of Dr. Robert Brent (Class of '53) and his wife, Lillian, for their long-term support for medical student scholarships, and a recent, substantial gift to initiate a visionary scholarship program that will be the subject of next week's newsletter.

Second, attendees at this year's ceremony were treated to truly special student and faculty presentations from Alexis Mott, Class of 2007, and Barbara Asselin, MD, Professor of Medicine.

And here they are:

Alexis Mott, Class of 2007

Alexis Mott, Class of 2007

Hello, my name is Alexis Mott; I'm one of the fourth year medical students here at Rochester.  I want to welcome you all and to congratulate you on such an important day in your life—your first, clean white coat.

It may be difficult to fully appreciate this day as your lives may be just a bit hectic – just a bit.
Many of you have moved all your belongings, some have packed up families, and others have had to say too many good-byes.  Your head may be spinning from new faces, new street names, and multiple trips to Target to buy everything that you forgot.

The stress of starting something new and so big is undeniable.  I remember that I cried twice my first week of school, once because I got lost in the highway system here in Rochester, which is aptly named "The Can of Worms." 

The second time I cried was out of pure relief.  We were out at dinner for our classmate Lisa's birthday.  I cracked open my fortune cookie and pulled out the little white paper which said these words, "The struggle is over."  Ahhh, I thought, it's over.  It was if that cookie knew how it feels to be a new medical student.  It knows how hard we've worked to be here, how many hours and insecurities we've toiled through.  It was as if the cookie said, "The wind is at your sails, go forth with ease."  I promptly ate that little cookie.  It was delicious.

So, if you can, take a breath and look around you. You are surrounded by so much enthusiasm, so much support, and newness.  Yes, you are about to work very hard, but you've done that before.  Yes, there will be obstacles, but you will rise to them, like you always have. 

And your white coat will be your survival kit.

The first day of third year, I went in with my white coat practically bullet-proofed with black pens, meal bars, containers of Advil, mints. My mom suggested a sewing kit, but I thought that was going too far.  So I just put that in my locker. 

I can tell you that slowly you will become less worried, less afraid of anatomy lab, of tests, or the spooky attending physician, and you will become more familiar with your surroundings. Best of all, you will make friends, you may even fall in love.

You will get more into your studies, sometimes a little too into it.  You will begin diagnosing yourself with all sorts of diseases.  During pediatrics, I was certain that little bump on my arm was ring worm waiting to take over my body.  In OB/GYN, an ovarian cyst was just about to rupture inside me.   Psychiatry left me with several personality disorders, and a few left over to give to my mom.

But how quickly those worries fall away to the real illnesses you see the patients dealing with. 

My first week of third year, I was in the pediatric intensive care unit.  I was asked late one night, to be the timer for pronouncing a one month old brain dead which meant I had to call out at certain time intervals as the team monitored him.  I stood with the group as they removed his ventilator and watched his vital signs change.   I felt so helpless, but I could do one thing, and that was count.  I held my watch so tightly in front of me, not moving an eye off of it, counting out loud for 8 minutes.

I remember being on an oncology elective and being sent in to see a young man for what I was told was a standard follow-up visit.  We were behind schedule, so I grabbed his folder and just went straight in to meet him.  As I introduced myself lightheartedly and got settled, I saw the first page of his chart.  It was his lab results from his bone marrow biopsy.  I realized he was not here for a follow-up; he was here to find out if he had leukemia.  I had the answer in front of me, and he knew that I knew.  It was not in my realm to tell him this, so I politely excused myself and got the real doctor in. 
 
You will have nights where you are tired and weary, maybe even tearful, or nights where you're back at Target at 10:00 pm buying enough underwear to make it until your final exam.  You will say the wrong thing – And you will say that wrong thing to the wrong person.  You will make mistakes, like when you're using the cool adhesive suturing glue in the pediatric emergency department,  don't accidentally glue the resident's finger to the child's face.  Parents don't like that.

But you will also learn more than you can imagine, you will call your parents and your friends and say "You won't believe what I did today...I put in an IV, and only on my 4th try!" Or even better, "I delivered a baby!" 

And you will keep some things to yourselves, like the ovarian cancer and metastasis you saw inside someone during surgery.  Or the shaken baby that could not be resuscitated.  Because those things are humbling.  They are not triumphant.

I was grocery shopping recently, and I saw a woman, about 40 years old, pushing her cart down the aisle.  Every few seconds her arms would fly out and move around without her control.  She tried to hide it, to make it look like she was fixing her hair or reaching for something and then changing her mind.  But I knew that it was most likely chorea – a dance-like movement sometimes associated with Huntington's disease. It was painful knowing this, like having a bad secret that no one else in the store, giving her sideward glances, knew, but it was also extraordinary.

When I was a kid, I loved the idea of knowing a secret.  I loved magic decoder rings, and Pig Latin, and invisible ink.  And that's what medical school is like.  You start to see all the clues coming together. You start to see things that others do not.  And you realize that everything you've learned so far, everything you've forgotten, all that studying, it's all worth the trouble. Because it is a privilege.

In a few years you will look down at your trusty white coat, a little more of a "gray coat" at that point, stained with coffee spills and slashed with pen marks and you will realize how far you have really come from this day. 

And then I recommend you buy another clean, white coat.

Barbara L. Asselin, M.D., Professor of Medicine

Barbara L. Asselin, M.D., associate professor of Pediatrics and Oncology at the James P. Wilmot Cancer Center

On behalf of the faculty of the School of Medicine, I join the Deans in welcoming you, your parents, family and friends to the White Coat Ceremony of the Class of 2010.  I am honored to join you today at this special occasion and share some experiences from my journey as medical student, resident, and now pediatric oncologist for almost 20 years. 

When Dr. Lambert asked me to speak on behalf of the faculty at your white coat ceremony I was initially struck by the irony of the situation.  Did he know that I haven't worn a white coat in over 10 years?  Could I speak about the power of the white coat when I no longer wore one?  I tried to remember back to when I stopped wearing my white coat.  It wasn't a political statement or really even a conscious decision on my part.  It certainly wasn't because I wasn't proud of it.

Getting into medical school (not to mention graduating successfully) was a most important accomplishment in my life.  I dreamed of becoming a doctor since I was in the third grade.  In those dreams I wore a white coat (just like my mom and dad).  

In thinking about my white coat and what to say today, I reflected back on these moments in my life as a young doctor.
 
During my training in PHO, I admitted a little boy named Kyle.  He had leukemia and a dangerously high white blood count.  During his initial evaluation he was very talkative and I explained that his blood was sick and that he needed strong medicines to make his blood better.  Unfortunately, he developed many of the life-threatening complications of the treatment thus spending several weeks in the intensive care unit on a ventilator.  When he was moved back to the regular pediatric unit I stopped by to see him and happened to be wearing my white coat.  He refused to talk to me and just turned his head towards the wall.  The next day I came back, but left my white coat at the desk.  This time he let me stay.  He fidgeted in bed, staring out the window, but didn't complain when I picked up the deck of cards from the bedside table and started to shuffle them.  "I bet I can beat you in a game of "Go Fish"," I said.  He stared for a while longer, occasionally peeking out of the corner of his eye to see if I was still there.  While I shuffled with my cards I said quietly, "I'm really sorry you got so sick from the medicines, Kyle, but you know they are working and that means you will be able to go home soon."  My reward was that he picked up his cards and started to play.  He quickly perked up, giggling with every time he told me proudly, "Go fish!"  Every day after that we played a quick game of "Go Fish" until the day he got to go home.  Whenever he saw me in Oncology Clinic, I was the doctor that knew how to play "Go Fish".
 
One of my saddest moments has also been one of my most precious experiences.  A young lady named Amanda was originally diagnosed with a brain tumor when she was 2 years old.  I cared for her until her death 2 weeks after her 21st birthday.  Amanda was the most medically challenging patient I have ever cared for.  Her problem list included developmental delay, seizures, growth failure, diabetes, osteoporosis, chronic infections, and hearing loss – just to name a few.  The list filled a complete typewritten page in her chart.  Her list of medications filled a second page.  What the chart didn't tell you is how her smile and laugh could light up the whole clinic.  Despite repeated surgeries and extensive chemotherapy treatments, the tumor continued to grow.  After her death her mother sent me a picture of Amanda and me.  She had framed it with the following quote,         

"When we ask ourselves which person in our lives means the most to us, we often find that it is the person who can be silent with us in a moment of despair, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a person that cares."       
~Author unknown

I was humbled by those words. 

In the end, when we all were powerless to change the course of events, I knew that I made a difference by being there, caring for her even when there were no more chemotherapies or treatments that could make her better.       

Joshua was a rambunctious, tow-headed 4 year old when he was diagnosed with a melanoma of his pinky finger.  After several family meetings about the best treatment strategy we all agreed that amputation of the finger, and part of his hand gave him the best chance of a cure.   But his father struggled with "how would he ever explain to his son why he let the doctors cut up his hand that way".  Two weeks after the surgery Josh was on his way to Pediatric clinic for a dose of chemotherapy when he said, "Mom, let's play the Dr. Asselin game.  I'll be Dr. Asselin, you pretend to be me."  He pretended to listen with a make-believe stethoscope and check ears and eyes with a make-believe light.  Then he held up both hands and said, "Look Mom, Dr. Asselin fixed my hands."   Waving the unaffected hand, he exclaimed, "She made this one bigger!" 

I cherish these experiences, each and every one of them, both joyous and sad.  As I reflected back on these stories, I realized that the lessons from Kyle, Amanda and Josh had been lessons of the heart:  Even when the diagnosis is made, the correct treatments given and despite the best that medicine has to offer there is still something more to the art of medicine.  Offering small words of comfort and concern is as important as all the tests and treatments.  You might say these are the lessons of a white coat.     

Let me share this advice from the wise old fox in the book, The Little Prince:

"And now here is my secret, it is only with the heart that one can see rightly; what is essential is invisible to the eye.  It is the time you have wasted for your rose that makes your rose so important.  You become responsible forever, for what you have tamed.  You are responsible for your rose."

Now imagine this passage reworded with the words "white coat" to replace "rose".

Only with the heart can one see rightly; what is essential is invisible to the eye. The secrets of the white coat are invisible to the eye.

The white coat is a symbol of the privilege of being a physician.  Wearing your white coat will open the lives of your patients.  They will share things with you and trust in you, solely because of that white coat. 

The white coat is a symbol of your knowledge and skill. 

Among the most important skills are to recognize your own limitations and to know when to ask for help.  The ability to say three words, "I don't know" is crucial to every good physician.  Recognize that patients will be among your best teachers.  Especially as a student there are many patients and families that will know more about their disease and treatment than you.  Acknowledge that and learn from them.  Each patient has an important story to tell.

It is the time you have sacrificed that will make the "white coat" so important. 
No matter what your experience prior to coming to medical school, you will be required to put forth great effort and hard work.  You will spend hours stuffing your brain with mind-numbing amounts of information.  It will keep you from doing things that are important to you.  Friends and family may tell you at times that they feel you have chosen your white coat over them and at times they'll be right.  Maintaining a balance is something that will require careful evaluation of what's important in your life.  In the end, the choices will be unique and personal for each one of you.
 
Your white coat also comes with responsibilities. 
It is a responsibility to hold a patient's life in your hands. 
It is a responsibility to hold their intimate life's details in complete confidence.   Developing a diagnostic plan and therapy plan are only part of the challenge in truly caring for a patient.  At the same time that you are learning about the disease, diagnosis and treatment, you must learn about illness, the patient and yourself.

As I reflect back on these twenty years and look forward to the next twenty years, I realize that the power of being a physician ultimately comes from inside and not from the white coat. 

The white coat is a visible symbol for all that is the essence of being a physician and healer.  Although you can take off your white coat, hang it in the closet or choose not to wear it you can not set aside the trust and responsibilities of being a physician. 

I hope these stories will remind you during the long nights ahead that there is always a person attached to the disease and that giving comfort is a fundamental task for the physician.  May these stories also remind you of the wonder of mastering the skills, the delight of a successful treatment and the intangible rewards of caring, no matter the outcome.

The next four years of your life will be dedicated to medical education.  Amid the piles of books, and hours of studying to educate your mind, remember to educate your heart.  Remember Kyle's story and that sometimes a game of "Go Fish" or just listening can be as powerful as any medicine.

As Martin Luther King said, "Some of you will be famous.  All of us can make a difference." 

Many of you will become famous, some of you will go on to make important scientific discoveries, but all of us can make a difference in this world. 

The Class of 2010 can make a difference.
That is the lesson of the white coat.
You can make a difference.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry