Dean's Newsletter
Archive of previous newsletters
Welcome the Class of 2011: Orientation and White Coat Ceremony
September 10, 2007
Each year, the first day of classes for our new medical students is preceded by a week of orientation. This begins on Monday with an introduction to the curriculum and a welcome picnic at my home, and culminates on Friday with the Robert and Lillian Brent White Coat Ceremony (see 9-6-06 Dean's Newsletter). In between are a variety of orientation activities. Important among these are a series of Professional Development group meetings, where students are led by faculty and more senior students in identifying different aspects of professionalism in the field of medicine. They also design and coordinate outdoor recreational activities with children living in Rochester, which serves as an introduction to the importance of community service--over 70 city children participated this year. The week's activities, which this year took place from August 13th-17th, also included orientation to the library, athletic facilities, infection control and other pertinent topics.
At this year's White Coat Ceremony, Jonathan Smith, who is beginning his final year of medical school, spoke in a whimsical yet eloquent fashion about the white coat and its "accessories." Then, Dr. Elizabeth McAnarney--a very wise and experienced clinician, educator and administrator, with roots as a developmental pediatrician--gave a powerful address about the meaning of the white coat in connection with one's developmental passages into the profession of medicine.
Here is what they said:
THE THINGS WE CARRY
Jonathan Smith
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Jonathan Smith |
This morning, I am supposed to give you a student's perspective on receiving your first white coat. I say first because these things pick up stains like you wouldn't believe. This is actually my third, and I got it yesterday because of a stain that was either blood, betadine, chocolate, or—well, I wasn't sure, and I wasn't going to be able to get through this knowing those of you in the front rows were trying to figure out what it was.
I feel kind of silly talking to you here, because three years ago, I was sitting right where—you—are, and I see your other speakers, your deans, and I think, what can I add to what they could tell you about what it means to wear a white coat. I'm pretty new at it myself. So I'm going to steer clear of telling you what it means to be a doctor in a long white coat. All I know so far is what it's like to wear this short one, and I've learned most of that just this past year. The next two years are important too! They are going to build the framework on which you'll wear this coat, because believe it or not, two years from now you're going to be a walking body of medical knowledge—often with a depth of understanding of the basic science that rivals anyone on your floor team—even when you've accidentally left your plethora of pocket reference books at home.
In a sense, the coat is just a symbol, a way of marking you as part of the team, as a student of the healing arts. That, and it does have a lot of handy pockets for those reference books.
So what I'd like to talk about isn't the science that the white lab-coat represents, it's the way the white coat marks you. Let me explain: later today, a patient will tell you a story. You've heard a lot of stories in the past—as people, we are avid consumers of stories. Since you decided to study medicine, you've probably heard medical stories from both family and friends, about their aches and pains and struggles with illness. So what you will hear this afternoon might seem very similar—but it will feel completely different. In fact, it will probably feel a little strange. You are now starting a transition from student, concerned family member, and caring friend, into something that is a little like those things, but also different: you are entering in the doctor-patient relationship.
While the white coat symbolizes many things, it also serves to help you mark this transition. You will now listen with different ideas, different goals, and new feelings of responsibility. You will listen today, and from now on, with a new weight on your shoulders, and while you may not feel it immediately when you are helped into your coat in a few minutes, it will quickly become apparent. The coat you carry out of here will be both a new weight on your shoulders, and a new bond that unites all of you—from different backgrounds, with different paths to this place, now bound together by the demands of the white coat.
When I was thinking about these things, I was reminded of Tim OBrien's short story, "The Things They Carried," in which he describes a platoon of soldiers in Vietnam through their various individual and common possessions. He uses personal effects to denote character and responsibility: the officer carries the map and compass, the medic carries morphine and additional first aid supplies. Throughout the story, you are stuck with the sense of weight, both literal and figurative, that these men bear, and of the bonds between them. Although the story you are embarking on is radically different from the one O'Brien tells, some similarities struck me.
First of all, you can tell a lot about someone by what they keep in their coat. Almost all of us carry a stethoscope, for instance, because even as students we use it all the time—and because they tend to grow feet if you put them down. Keep an eye out for my first one, it's blue with grey earpieces and it's somewhere in the Emergency Room. I'm offering a small reward. We also all carry a supply of pens, and most of us carry some assortment of reference books, which range in portability from practical to implausible. Incidentally, if you are not wearing a coat, don't try keeping this one [Mont Reid Surgical Handbook] in your scrub pants pocket. They will fall down, which, if you're scrubbed into a surgical case and can't touch anything but the sterile instruments or the patient's gallbladder, can be very awkward.
You can even glean some ideas of people's interests or specialties from their coats. More than one reflex hammer? Think neurology. Stethoscope covered in a fake giraffe? Probably pediatrics. Three or more packs of suture with knots tied to all of their buttons? There's your aspiring surgeon. What you will quickly notice, especially in your third year as you start to work on the hospital floors, is that all of these things get very, very heavy.
And this is just the physical weight. The vast majority of the weight you feel will not come from this book, or this one, or even this [Mont Reid again], or the seven review articles that your attending wrote and felt compelled to print out for everyone. No, it'll come from your own feelings of responsibility for your patients, who will see the white coat and, not knowing that the length of coat means anything, quickly assume that you're a doctor, and that you can answer all their questions, while you will never feel more acutely aware of the limits of your own knowledge. For instance, on my last rotation a patient with an inflamed spinal cord asked me if he'd ever walk again. What was even more unnerving than giving him an ambiguous answer—it depends, people with your disease can go either way—was the next patient, who asked me why we couldn't find anything wrong with her when she hadn't been able to move her legs for several days. I didn't know. Every test we ran was negative. It was just that—we didn't know.
And there will be times when patients see that white coat and ask you things that humble you even further. They'll ask you things that remind you that wearing this coat brings you into a field where people confront their own mortality. And they expect you to help them come to grips with it. One morning on a surgery rotation, I was visiting a patient we'd operated on who was in the ICU. He wasn't doing very well. He motioned me over, and asked me something I couldn't understand. I didn't even grasp what he wanted until a resident helped translate his request: he wanted us to stop his ventilator and his other life support. Setting aside how I felt about the outcome of his surgery, I felt stunned. I hadn't even been able to understand this most important of his concerns. End of life questions come with the white coat, but they will still surprise you.
As a result, you might feel overwhelmed. You might feel small and insignificant. And you might feel amazed at the courage and insight your patients have about their condition. What you will find comforting is that not only does the coat single you out to patients as a source help with these issues, it unites you with your colleagues, who are all undergoing the same things, and who will be there to lend a comforting hand, or a white coated shoulder to cry on.
These, then, are the things I know about wearing a student's white coat. They stain. They are heavy, both literally and figuratively. And they bind all of you together into a community of learners, of healers, who are going to be become very capable of shouldering such a weight. Good luck, and enjoy your first white coat.
PASSAGES AND PASSION
Elizabeth McAnarney, M.D.
Professor of Pediatrics
"To be a physician,
to be permitted,
to be invited by another human being,
in the circumstances of that crucible which is illness,
to be a trusted participant in the highest of dramas,
for these privileges,
I am grateful beyond words."
(Unknown)
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Elizabeth R. McAnarney, MD Professor and Chair Emerita Department of Pediatrics |
Today is your official passage into the medical profession. We are reassured knowing that you will carry forward the great tradition of our profession to provide medical care with utmost compassion and skill. We hope that you will remain ever-passionate about caring for your patients throughout your professional life-times. Please do not let the passion about becoming a doctor that you are feeling today about serving others diminish over time. There will be challenges - that is life, but the well-being of your patients should always remain a major priority in your lives.
First, I would like to comment on the white coat as a symbol of medicine. In the mid-19th century, the beige, long laboratory coat of the basic scientist was adopted to distinguish medical doctors from impostors. At the end of the 19th century, the white coat replaced the tan coat among many physicians and became a symbol of the medical profession, much like the stethoscope. White represents purity, cleanliness, and compassion. The white coat, also, provides boundaries (not barriers) between patient and physician. (1)
Second, I would like to reflect on your "white coat" passage into medicine today as one of several rites of passage. Rites of passage are developmental events celebrated by family and friends and often occur at a time when individuals have growing capabilities, resulting in increasing expectations from society. Society's expectations of your role as a physician are all ready set into motion by virtue of your matriculation into medical school. Your being here today reflects successful passages through earlier developmental events.
Culture largely dictates its rites of passage; the culture of medicine determines this rite of passage. Most rites of passage are marked by ceremonies/rituals, symbols reflecting the values of the society, and celebrations. This is true today. We have the ceremony as the ritual, the white coat or the robe as the symbol, and the celebration with family and friends after this event.
I would like now to consider several developmental tasks through which you, as medical students, will probably pass (identity formation, cognitive development, and the role of family and friends), much as we have in previous developmental stages. The concepts among different developmental stages are similar; the specifics differ depending upon the rite of passage.
The acquisition of identity is a common developmental theme throughout life. (You may be sitting there thinking, I certainly think I know who I am by now!!) There is a new identity associated with your becoming a doctor, first as a medical student, and subsequently, as a physician. For some, this identity will come relatively easily; for others, it may be more of a struggle. The questions for you as medical students might include, "Who am I as a medical student?" especially if the patient assumes you are a physician and you know you are not; or the question of "Do I really want to be a doctor?" having observed more closely the day-to-day challenges of the profession. These musings about professional identity are common to medical students and physicians, and should not be disquieting, as they are all part of becoming an introspective doctor. Hopefully your professional identity will be a work in progress for your entire life-time as you reflect on whether you are the best doctor you can be.
Cognitive development is important as you acquire the knowledge and skills of a doctor of medicine. A hallmark of our medical school curriculum is the training of active, life-long learners in the medical profession. This process of learning is particularly intense during medical school, as the sheer volume of information is immense. (You may feel sometimes that you are building a bicycle and riding it all at the same time!!) Now, probably for the first time for many of you, others' lives will depend upon your knowledge. It is absolutely critical that you seek new knowledge actively every day for the rest of your lives. Medicine is a scholarly, cognitive profession.
You may experience some cognitive frustration in your first year of medical school. In college and for some, in the work-place, you have honed your formal operational skills through study and debate (as you may remember from your college psychology courses, formal operational skills reflect the ability to think about thoughts, think ahead, and participate in abstract thinking). Much of clinical medicine is applied and may require your being facile in far more concrete operational skills (that is focused on the here and now) than you may have been in a long time. You will need to be flexible and utilize all your cognitive capacities, this time on behalf of your patients.
In all stages of our lives, our families and friends are of utmost importance. We celebrate all your families today; it was they who guided you through your early years. During specific periods of development, however, we must renegotiate our relationships with our families-of-origin. This is often a gradual process as time moves on. Separation from the family-of-origin is crucial for the adolescent to achieve the tasks of early adulthood. So, too, you as medical students/young physicians will be experiencing further separation from family. It is important that you as families understand this need for some separation related to your child's professional duty, so you can be supportive. For example, there may be confidential information patients share with us as physicians that cannot be shared with anyone, other than one's professional colleagues. That is, ethical constraints do not allow such discussions. There will be times that the physician cannot join one's family for important family events because duty calls. Families may not appreciate fully this "call to duty." Misunderstandings about ethical constraints and absence from family events may cause strain among one's family, some of which can be expected. Renegotiations of family relationships occur gradually and subside with time.
Friends are very important throughout our lives, but especially with one's peers in medical school. Many of your medical-school class-mates will become life-long friends. You are bonded by unique shared experiences as well as by the ups and downs of becoming a physician. Some have used the analogy of the relationships developed in medical school as similar to those of relationships of persons in the military who developed life-long friends in boot camp together!! Your passage into the profession of medicine today shares many commonalities with cultural and developmental events occurring over the ages.
Let me last now having commented on passages, briefly address the theme of passion for the care of your patients and for your profession. The privilege of being a physician is one afforded few. Please remember that every day, and pursue the healing of your patients and your being a doctor with passion.
Your teachers in medical school and perhaps, your own doctors, whom you will remember for many years to come, are those who combine passion about healing with compassion for each individual for whom one cares. Passion comes from the depths of one's being and is measured by our dedication to our patients and to the highest ideals of our profession.
I shall end this address by quoting Dr. Craig Benson, a passionate and compassionate graduate of Class of 2007 at the University of Rochester. I am including portions of Craig's graduation address as a tribute to you as medical students and in honor of all the medical students at the University of Rochester who have preceded you. Four short years ago, Craig was sitting where you are today. Craig is now a Medicine-Pediatrics resident at the University of Rochester.
"Remember your first patient,
in HSF anatomy class,
Remember your first test,
you never thought you'd pass.
Recall the first heart you heard
with your new stethoscope
Recall the first hand you held,
to give a patient hope.
As you continue on this journey,
the best advice I can give
always put the patient first.
That's the only way I know how to live.
For whether you're first or last,
that won't determine how you fare.
Because what really matters in life,
Is how much you care." (2)
Meliora,
David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
References
1. Jones V. The white coat: Why not follow suit? JAMA. 1999; 281:478.
2. Benson, C. The University of Rochester School of Medicine and Dentistry Commencement (see Dean's Newsletter 6-7-07), with permission of the author.
