whither the white coat?

Does being professional require wearing a "white coat" or other symbol of being a doctor?

You have inevitably heard about "white coat syndrome" where patients have an adverse reaction to seeing people dressed in the typical doctor's garb. This adverse reaction can be crying by a child, hypertension by an adult, or otherwise not being at one's best. It is generally assumed to be related to fear of the person wearing the white coat, and perhaps the coat has gained some living attribute, some intrinsic property that compels this adverse reaction, and has no relationship to the person (student or professional) wearing the coat.

My argument is that the only reason the white coat has gained such a bad reputation, is because of the behavior of those who are wearing it.

Personally, I do my best to NOT wear one, but I do find that when I am the attending physician on the in-patient unit, it is almost impossible for me to keep hold of all my essential belongings without one. My usual daily attire is a business suit, but when I am on service I tend to dress slightly less formally.  So I will typically wear a blouse and skirt or slacks. Most of the flattering styles for women do not include pockets, so I wear my white coat so I can have a few dollars in case of an emergency need for a coffee infusion, can carry my blackberry and a pen, some scrap paper to take notes when I receive calls asking me to accept patients from other hospitals, and my ever present patient list.

Here is what I see in many of my co-white-coat wearers (students and  residents predominantly).

Knock on the door in a perfunctory manner, barge in, start talking. No eye contact with the patient, although perhaps with the parent(s). This is a sudden onslaught of many folks, dressed in white coats (well formerly WHITE, now usually gray) who barge into a room, fail to engage with the child and start acting in ways that resemble an ATTACK on the poor kid. Doesn't much matter whether it is an infant, toddler, school-age child or adolescent. The response is predictable--at best withdrawal, at worst, screaming and an active attempt to escape.

What do I do differently?

Well, depending on the child's age (always important) I may not walk directly in to the room. A peek around the door after knocking (AND being acknowledged), perhaps in a very tentative manner, may make the child curious, and the parent usually catches on quickly to what I am doing. I make eye contact with the child, and engage him/her in conversation--NOT about the illness, but about anything else. Can you find.... What do I have on my ears (I often wear silly critters as earrings, and some kids get a kick out of finding them under my hair), are you the princess who lives in this bed? or king or queen, etc. Once must be doing something to engage the child while gaining the trust of the parent. Not easy, but definitely worth it for most pediatricians.

While I try to make sure my white coat is always clean and neat, I am certain I am dressed in such a way as to foster trust and respect on the part of the parents, but I also want the child to not be afraid of me. I can't be very effective if Iam unable to fully examine the kid's belly, or chest, or whatever part may be the most crucial to my being able to make a diagnosis, or determine the success of my treatment.

I want, no, I need the trust of both the parent and child. I want the parent to be my partner in the medical care I provide, even though I am not the child's primary care doctor, and may never see them again. I never separate the child from the parent, unless that is absolutely necessary for medical or legal reasons, but rather involve the parent to hold and comfort during my exam, or help to demonstrate something ("push on that spot right there"  "get johnny to take a deep breath" "have Betsy show YOU where it hurts"). If at all possible, I ALWAYS have the parent hold the child during my exam, and only use the bed on rare occasions.

I seem to have gotten a bit far afield of my initial topic--what makes you look like a professional?

Clearly from what I have written so far, you know that I believe the white coat is neither sufficient nor necessary. It can be helpful to make it clear just who is the doctor in the room (after all these years, some people still think I may be their child's nurse), but it can also be harmful. I would urge all doctors in training (students or residents), not to hide behind the white coat, not to use it as the excuse for why they can't connect with the child.

Connecting with your patient is still one of the most therapeutic things a physician can do.

This will never be replaced by clinical practice guidelines, protocols, electronic messages or standing orders. Connecting helps you feel good after the patient encounter. In fact, it is ALWAYS my goal that somewhere between walking into and out of the patient's hospital room, I WILL get a smile from my patient. It doesn't always happen, of course, but when I fail on one day, it seems I always succeed the next. Perhaps I act a little crazy in the room. I play peek-a-boo, I translate the adolescent's language (usually they speak "shrug"--every time you ask them a question they just shrug their shoulders, so I "interpret" each shrug for them, and almost always get a chuckle and then they start to talk to me), I tell them their ears are located on their feet--whatever I need to do to be accepted by the child, while I talk good, straight English (or other language through a translator)-not medicalese to the parent. The parent knows I am not really a total goof-ball, but the kid is left thinking I just might be.

Tomorrow, or whenever the next time is that I am going to walk into that room, they are just a little bit less afraid, and I can connect just a little bit better, even if I am still wearing my white coat.

Recent Comments

Thanks, Lisa. All healthcare providers need to learn to deal with children in an appropriate fashion. Someone told me just recently that her child's doctor has NEVER played peek-a-boo, or done anything else like that to gain the child's trust. I feel sorry for that child but even more sorry for the physician.

This is an inspiring blog. I definitely agree. My daughter's pediatrician, Dr. Althouse never hid behind the white coat either and helped my daughter and her parents feel comfortable and part of the exam. Thank you for sharing!

THANK YOU! Great GREAT post!!!! It is so important for doctors to connect with their patients...it is what distinguishes a good doctor from an outstanding doctor. You can have the smartest doctors in the world, but without that personal connection, you will never feel comfortable with them and it inhibits the best possible care. I have the highest respect for doctors who can come down to the level of a child and interact with them and be silly with them; it shows that they truly care. Thank you for being passionate about this and for taking the time to acknowledge how important it is. The next time my daughter has to be at Roanoke Memorial, I hope she has the privilege of meeting you.

Heather, I would be delighted to meet your daughter, but lets do it NOT in the hospital. I don't wish hospitalizations on anyone. Besides that I wouldn't want you to be disappointed in me as her doctor.

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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