The white coat is a time-honored symbol of doctoring. In most hospitals, physicians wear long white coats while medical students wear short white coats, symbolizing their ongoing training.
Despite being doctors, first-year residents at Johns Hopkins Hospital in Baltimore were traditionally relegated to the short white coat, separating them from every other physician in the hospital. “I think that's unique in the country,” said program director Sanjay Desai, MD, FACP, who is also vice chair for education in the department of medicine.
That all changed in July. Responding to some pushback from trainees, the program ended the tradition with its newest class of interns, who received long white coats. ACP Hospitalist recently spoke with Dr. Desai about the rationale behind the change.
Q: What does the white coat, short or long, symbolize in internal medicine?
A: The white coat itself dates back more than a century and, to my understanding, is largely rooted in the idea of when there started to become science that underpinned the decisions and the treatments that physicians were making. . . . One of the symbols of scientists was this lab coat, and I think that's when it really started to emerge as a professional symbol of physicians.
For us, we had two different lengths. The premise was that we believed finishing medical school did not make you a clinician; what made you a clinician was going through internship and owning the care for patients. . . . The short white coat symbolized the belief that you are a continuous learner now caring for patients. Secondly, for many of us that wore it, including myself, I'm very proud of my short white coat. It also symbolized one of the most meaningful shared experiences in my professional life, which was that intern year. For all those reasons, we had this tradition in our program probably for 40 to 50 years.
Q: Why did the residency program eliminate the short white coats for interns?
A: The recent graduates from medical school, the ones that have come to our program, don't view the coat the way I just described it, with pride and as a learner and in a shared experience, but rather [as] a symbol of hierarchy, a symbol of rigidity, and not promoting the values that we intended for it to promote. So it's for that reason that we eliminated it.
The process that we took to eliminate it is one in which we decided that we would examine everything that we do because the processes and the structures and the traditions that we have, those are not the values. The values that we really have are the ones that are rooted in patient care, in patient ownership, in this commitment to excellence, and the length of the coat was not a core value.
Q: What feedback did you receive from the residents?
A: I heard from a lot of people, and certainly from people on both sides of the issue. There is a group of people that believe that the short white coat continued for them, as it did for me, to promote those values and therefore we should hold onto it and educate people on the value that it's intended to promote. And yet, there are others that welcomed the change and felt that this is a modern adaptation and a reflection of responding to the current environment in a way that is attentive to people's needs. I think it's fairly mixed . . . [but] there was enough dissatisfaction about it that, to me, it felt like a distraction, and that was the reason to make the change.
Q: You trained at Johns Hopkins. How did it feel to receive the long white coat after intern year?
A: It is very powerful. For us that wore the short white coat with pride, we really looked forward to that day that we earned our long white coat. I hope that there's still some recognition that finishing intern year, you are different in capability and in emotional maturity than you were 365 days earlier, but that transition won't be symbolized with the length of the coat.
Q: What are the potential impacts of changing this tradition?
A: I think that there's impact now because people are emotionally invested in the change. . . . If you were to make a change and nobody cared, that would be unfortunate. The fact that people do care reminds me what a privilege it is to be part of a program where people feel such passion. At the same time, I think that this is going to be something that's accepted and probably not looked back upon in years with the same emotion. [Interns used to wear all white], and about 20 years ago that stopped. It was probably very similar. I think people were emotional about it then, and yet, now, it seems to be part of the past.
Q: Do you have any words of wisdom for other programs with similar traditions?
A: What we've learned from this is that we have to be ready to adapt and change traditions, structures, processes to reflect the attitudes and the context of the current learners. But what we were very careful to do is not compromise on our core values, and I would encourage others to do the same.