Friday, May 8, 2015

The Doctor's White Coat -- Dan W. Blumhagen, M.D.

PERSPECTIVE

The Doctor's White Coat

The Image of the Physician in Modern America
DAN W. BLUMHAGEN, M.D.; Seattle, Washington


     The social perception of the physician has changed during the past century. This is reflected in the changing use of a symbol of the profession, the white coat. This dress originated in the operating rooms, scientific laboratories and modern hospitals, each of which contributed to the social understanding of what it means to be a healer. Adding the cultural significance of “whiteness” reveals a broad spectrum of meaning surrounding the healing encounter, whose most important aspects are the authority and supernatural powers of scientific physicians and the protection of patients. A major force aiding in the adoption of this symbol was the shift in sick care from home to hospital, where it served to legitimate otherwise socially taboo behavior. Recent changes in how scientific medicine is publicly viewed have eroded these established meanings. The resulting tensions affect individual patient-physician encounters and interactions between the profession and society as a whole.
     ALL SOCIETIES have healers who care for the sick (1). The healer’s interaction with a patient is often surrounded by a symbolic system that expresses the implicit cultural concepts of what “healing” means (2). As changes occur in the social meaning attributed to healing, the symbols used to express those concepts also change. This paper will use the symbol-analysis approach, widely used in cultural anthropology, to examine the historical origins and the function of the symbol systems that surround American physicians and their patients. An understanding of how these were adopted first by the profession and then by the greater society will elucidate what it means to be a healer in American culture. This knowledge can be usefully applied to problematic patient consultations, as well as to understanding some of the conflicts that have arisen between the medical profession and society at large.

The Nature of Symbol Analysis

     Most physicians are aware of the importance of symbol analysis in individual psychotherapy (3). What is less widely appreciated is the application of a similar approach to understanding entire cultures. Anthropologists have found that symbols are often used as a way to express and reaffirm the
fundamental belief systems that a society holds (4). This is often done in ritualized events. Perhaps cultural symbols can be most usefully viewed as a form of communication, analogous to words in a natural language (5). Like words, they can be used in social settings to define the shared interpretation of “what’s really going on here,” to direct each actor’s behavior, and to express the dominance relationships that exist between the various individuals who are interacting, Since most symbol analyses have dealt with small-scale preliterate societies, there is no well-defined formula for doing such a study in a complex, literate society such as modern America. My approach here will be to look at doctor-patient interactions to determine what symbols may be used, then examine historical data documenting how these came into use and the original meanings they bore. Finally, the use of these symbols in the medial setting will be compared with similar symbols used in other American rituals to develop the full spectrum of meaning that they communicate.

Symbols of the Physician

     What, then, are the symbols surrounding physicians, and what do they mean? Table 1 shows how physicians are depicted in advertisements for medical journals and in newspaper comic strips. These sources were chosen because they represent stereotypes of the doctor as presented to the profession and to the public. They represent “all physicians in general” and so not merely reflect the idiosyncrasies of a particular physician.
     Table 1 shows that although there are some differences in the way physicians are depicted in medical and popular media, there appears to be four principal objects used to depict the doctor: the white coat, stethoscope, head mirror and a black bag. In this survey, there are only one physician depicted in a patient-care setting who did not have at least one of these items. The most frequent component of the image seems to be the white coat. Of 43 doctors pictured in patient-care settings (Table 1), 36 were wearing white. In the symbolism of white coats, the social concept of “what it means to be a physician” is summarized, intensified and extended (Figure 1). Its importance as the symbol of physicians is seen in that when the advertising media—a reflection of the current social stereotype—wish to depict a person with the authority of a physician, he is usually shown wearing a white coat. Although professionals are reluctant to articulate the meanings they attribute to white coats, on occasion, under stress, such interpretations may be given.
     The relationship between a physician and his patient is serious and purposeful, not social, casual or random. In this relation the patient unburdens himself or herself of a set of concerns regarding health matters and transfers them to the accepting physician. For a very long time it has been customary for individuals in society to dress rather formally when conducting serious business, and less formally when they are at leisure. The physician’s dress should convey to even his most anxious patient a sense of seriousness of purpose that helps to provide reassurance and confidence that his or her complaints will be dealt with competently. True, the white coat is only a symbol of this attitude, but it also has the additional practical virtue of being identifiable, easily laundered, and more easily changed than street clothes if accidentally soiled….Casual or slovenly dress is likely to convey, rightly or wrongly, casual or inattentive professional handling of their problem. Such a patient may response in an inhibited manner, fail to volunteer information, refuse to carry out a recommended diagnostic or management program, fail to keep appointments and to be uncomfortable enough to seek help elsewhere. The rapport, so anxiously sought for with your patient, may be irretrievably lost (6).
     To fully understand how the white coat has achieved this position, we must look at the historical origins of white coats as the symbol of physicians. I have been able to identify three major origins for the white coat as it has been used until fairly recently: the operating room, the scientific, specifically microbiological, laboratory and the hospital. Each add a layer of meaning.

The White Coat in the Operating Room

     Operating-room garb appears to have originated with the concept of aseptic surgery, which began in this country about 1889 (7). Photographs from that year in the Massachusetts General Hospital Archives show the surgeons and nurses (but not the anesthesiologist or observers in the balcony) wearing short-sleeved white coats over their street clothes. Mask and gloves had not yet come into use. The purpose of the coats in this setting appears to be twofold: to protect the patient from being contaminated by the physician, and to protect the physician from contamination by the patient during the procedure being performed. We will find that the white coat repeatedly serves to protect both the patient and the physician.
     Another implication that surgery has for the public image of the physician is its incredible power to send a person into a deathlike state, open the previously inviolable body cavities, correct whatever was “wrong,” and resurrect the patient, healed.
     I have said that the modern surgeon has become a popular hero…One has only to glance through the mouth’s illustrated magazines, or to turn a few pages of the latest novel to find him in the act of revealing his demonical subtlety or demonstrating his incredible skill. The tall spare frame is capable on emergency of strength and endurance that would make Sandow stand aghast (8).
     White coats had not yet become symbolic of this heroism, but the newly developing film industry ground out a remarkable number of amplifications of this theme (9). One such film, “Society Doctor,” is described as being “played in spotless white . . . and with an appropriate sense of glamor and notability . . . [The hero] persuades his best friend to operate on him, directing the work himself with the aid of mirrors” (10). In these quotations we see that the social image of the physician had become one of immense power and authority. These attributes were associated with the white clothing he wore.
     Even though the operating room provided one of the earliest examples of doctors wearing white, and provides some of the basic cultural meaning, it does not appear to be the main source. Stahel’s otherwise valuable article (11) confuses this point. With the goal of better aseptic technique, the white coats of 1889 rapidly became full length gowns, and were referred to as such (12). Aseptic surgery required that these gowns only be used in the operating room to avoid the risk of cross contamination. The back impractical for other patient-care settings (11). Additionally, the term “gown” in our culture usually refers to women’s clothing and thus is not suitable as an ambitious . . . upon whose shoulders the actual work of the institution will fall” (12, p. 265).
     Figure 2 clearly shows the divergence of white coats from operating-room gowns. There are three types of dress in the audience: the scrub suits of the surgeons who are clustered on one side; the street clothes of the vast majority in the middle; and the white coat of a single individual who looks as if he had just walked out of his laboratory to observe the procedure. The step that look the garb of the scientific laboratory into a clinical setting appears to be the main source of our current white coats. The term “lab coat,” the primary term used for the white coat, refers to this origin.

The White Coat in the Laboratory

     The representation of the physician as a scientist has a long history that culminated during the first decades of this century. In the middle of the 19th century, science had nearly destroyed the reputability of medicine by demonstrating that its cures were worthless, but it was unable to substitute more effective remedies. Medicine became simply one of a wide variety of healing cults and quackery (13). Despite this inauspicious start, both the profession and public turned to science as the means by which healing would come. After all, the laboratories, whose inventions had transformed night into day, could transmit messages instantaneously, and had revolutionized transportation, were certainly the most important hope for the conquest of disease. Physicians were urged to present themselves as scientists. Cathell, whose book The Physician Himself went through many editions between 1882 and 1922, advised: “Show aesthetic cultivation in your office arrangement, and make it look fresh, neat, clean and scientific” (14) [emphasis added]. Above all, one must avoid “forcing on everybody the conclusion that you are, after all, but an ordinary person” (14, p. 56). By 1922, Cathell had become more emphatic in describing “the office, the sanctuary—of an earnest, working scientific medical man . . .” [emphasis in original] as the place where one will make “judicious and intelligent use of your scientific instruments of precision . . . to assist you in curing nervous and terrified people by increasing their confidence in your armamentarium and in your professional ability” (15). The authority of science is seen as validating the practice of medicine.
The medical profession rapidly consolidated its position as a part of the scientific enterprise. Within a decade of the publication of the Flexner Report in 1910, medical education was restructured around laboratory science. The content of medicine changed. Textbooks were rewritten: Of all the books popular enough to go through multiple editions before the “progressive era,” almost none were still being printed when it ended. (This was ascertained by a review of the books in the open stacks of the Countway Library. The most notable exceptions, of course, are Gary’s Anatomy and Osler’s Textbook of Medicine (1892), both of which are still being printed in revised editions. There were no technical or theoretical advances that would outdate the former, and the latter was written by one of the men who led medical education during this change). Towards the end of this radical transformation of the profession of medicine, as a reflection of it, physicians became stereotyped as scientists wearing white coats. The message of power and protection emerge: While wearing a white coat the physician is able to handle safely the deadly scourges that plague mankind and is able to render them innocuous. One result of this perception of power was that physician-scientists were granted tremendous authority. No mere individual desired or beliefs were allowed to stand in the way of the public’s health as determined by medical laboratories (16).

The White Coat in the Hospital

     The shift in locus of sick care from the home to the hospital was the third historical trend. The basis for this lay in the development of aseptic surgery and modern diagnostic and therapeutic techniques, which necessitated the use of personnel and resources that could not readily be taken to the patient’s home. With the impact of the change in medical care, the image of the hospital changed from that of being a place where social outcast died to being the only place where the sick could be healed. The image changed from death to life. This was reflected in the change of the clothing of the healing staff. The black habits of the religious nursing order, for example, became the white uniforms of the modern nursing profession (17). Hornsby, then director of Micaehl Reese Hospital in Chicago, tells us in The Modern Hospital (12, pp. 543-5) that all people connected with the healing process (including patients and visitors) were to be dressed in white, whereas the nonmedical employees were to be given colored uniforms. White became associated with the institutions of healing, and it was within their halls that the use of white coats as the symbol of medicine was pronounced. Physicians in private practices have never completely adopted their use.
     This transition is most clearly indicated in the photo-graphs of house staff that often accompany a hospital's annual report. These pictures show that during the period 1905-15 apprentice physicians exchanged their street clothes for white coats and pants. Hornsby indicates that this was not merely for the convenience of the hospital laundry; indeed, "Intern's white uniforms are difficult to launder, and should be done by hand" (12, p. 601). In other words, there were compelling reasons for dressing interns in white that outweighed the economic disadvantages.

The Meaning of Whiteness

     Given the historical backdrop of the meaning of the white coat, what is added by the cultural conception of the meaning of whiteness? Originally, laboratory coats were tan and appear to have changed to white as they became associated with medicine. Why was not another, perhaps more functional, color adopted? Why were both the profession and the public so profoundly disturbed when Nobel Laureate Alexis Carrel wore black gowns in his laboratories and operating rooms at the fledgling Rockefeller Institute of Medicine (18)?
     The significance of white as a symbol of life has already been mentioned.
     Since there are few celebrations of life in our society, this meaning is derived from its opposite color, black, which is clearly the color of death and mourning. The association with purity has also received comment. But this purity contains two strands of meaning: First is the concept of innocence. No shadow of malice, of intentional harm, can mar the white coat—the patient is safe in the hands of this powerful figure. Second is the purity of unaroused sexuality, particularly as this meaning is evoked in another ritual that uses the white bridal gown.
     Closely allied to the concept of purity is the concept of superhuman power. The saying "cleanliness is next to godliness" originated long before the germ theory of disease! Whiteness as an attribute of superhuman power, at once irresistibly attractive and infinitely dangerous, is clearly expressed in Melville's Moby Dick (19) and, as has been shown, was explicitly applied to physicians. In religious symbolism, Christ and the saints who have exercised their power over death and all other human frailties are robed in white (Bible, Revelations 7:9-17) But these are not merely powerful, they are supremely good.
        A final meaning comes from the term candor, itself derived from the Latin candidus (white). This impartial truth-telling is often portrayed in statues of "justice," who is usually depicted wearing white.
        If symbols affect behavior, the use of the white coat should affect how patients and physicians act. There appear to be two behavioral changes that have been mediated by the white coat: the physician's access to his patient's body, and the shift in the locus of the sick role from the home to an institution.

Body and Sexual Taboos in American Culture

     In many societies, the most powerful symbol systems are found in situations where strong social values appear to be challenged (20). One of the strongest beliefs in our society is the inviolability of a person's physical body (21, 22). There is even a legal term for the violation of a person's rights over his own body: battery. Merely touching another individual without that person's permission is to be at jeopardy of civil and criminal action (23). The extent to which the physical examination is a serious breach of social custom has been clearly stated by Lief and Fox (24).
     The amounts and occasions of bodily contact are carefully regulated in all societies, and very much so in ours. The kind of access to the body of the patient that a physician in our society has is a uniquely privileged one. Even in the course of a so-called routine physical examination, the physician is permitted to handle the patient's body in ways otherwise permitted to special intimates, and in the case of procedures such as rectal and vaginal examination in ways normally not even permitted to a sexual partner. The physical body is not merely a threat to the person whose body is revealed, it is also considered to be dangerous to the one who is exposed to it. This is the basis of much of the American film rating system. Given these taboos, the perfunctory way that physicians are given permission to do the most intimate examination is remarkable.
     The individual must stand before his doctor man to man, unclothed physically, mentally and morally, revealing to him as he does to no other mortal, not even to his father confessor, the secrets of his inmost soul; submitting his person to the most thorough scrutiny of the physician and to varied tests, physical, clinical, instrumental and hat not, and without hesitation committing to his keeping the keys of the family skeleton closet (25).
     Physical examinations of apparently healthy people are a relatively recent phenomenon. Referring to the late 19th century, Duffy writes: "Physical diagnosis remained handicapped by the reluctance of patients, particularly females, to bare their skins to the probing, palpation or percussion of the physicians" (26). Rectal and pelvic examinations do not appear to have been frequently used. As late as 1927, Richard Cabot, a prominent medical educator, claimed that "it is not and should not be a part of the routine physical examination to examine the rectum" (27). Buttressed, however, by the successes of medicine in improving public health, a campaign was waged from 1922 to 1929 that promoted periodic physical examinations as a means of improving the individual's health (28). These included pelvic and rectal examinations.

Monte Cristo Up-to-Date


     For this crusade to be successful, the cultural dangers of the physical contact had to be muted. A mechanism was needed that would reinterpret an ordinarily taboo activity into a socially acceptable, even desirable, one
     A set of symbols was needed to protect both the doctor and patient in this dangerous setting. The white coat, with its meanings of bilateral protection, purity, goodness, and unaroused sexuality, was ideally suited for this task. In the less-threatening situation where a male physician examined a man, the white coat was all that was needed: The patient was nude (30). When the physician examined a woman, however, a reciprocal symbolic dress was required, leading to the development of the examination gown. In one of the early descriptions of such a garment, the symbolic themes come out. Fisk (30) claims that this gown "gives the examinee a sense of protection and lessens embarrassment." The disparate treat-ment of men and women could not be maintained, and soon men, too, were offered the protection of examination gowns.
     The second behavioral change was a shift in the concept of where it was appropriate to act sick (31). Previously, of course, illness had been a personal drama played in the bedroom, the most secluded, intimate, and protective area of the home. The physician could enter at the invitation of the family and be made privy to the physical and behavioral secrets contained therein without violating any social norms. Only those unfortunate persons who lacked a protective home sought care in an institution. It was only the "fallen women who enter hospitals" (32), that is, only those people without anything worth concealing or without anyone to shield them. Symbols were required that would protect patients from the unwarranted intrusions that could occur in an institution and that would legitimize private behavior in a public place. The physician's white coat and the patient's examination gown met these needs perfectly.

     These shared meanings direct patient and physician behavior in the following way: The physician is an active scientist, the patient is passive material; the physician prescribes, the patient complies; the physician is self-concealing, the patient is self-revealing. Clearly, as long as this social definition of the healing encounter exists, the physician will dominate the setting.
The above set of symbols appears to have been fully functional by the early 1930s and remained largely intact until recently. There were minor changes, such as the adoption of blue or green garb in operating rooms when high-intensity lighting made the glare from white drapes unbearable, but these pastel shades did not conflict with the underlying value system as black or red, for example, would have.
     Other practitioners found that some of the meanings communicated by the white coat were so overpowering that it interfered with their practice. Pediatricians and psychiatrists have discovered that this mark of authority has a tendency to overwhelm their patients, and they therefore tend to wear pastel coats or normal street clothes. As has been noted, many physicians, particularly those in private practice, did not adopt the white coat. Nonetheless, these trends did not affect the public image of what a physician should be. If anything, the beliefs were intensified, as is evidenced by the meteoric rise in the funding of medical research after World War II, which resulted in the National Institutes of Health and much of the rest of the academic medical enterprise (33).

Current Trends

     During the past decade, however, much of this has changed. Physician-scientists who were once seen as validating medical practice no longer necessarily protect and heal patients, but may endanger them. A good example of this attitude is seen in the widespread laetrile movement, which is perceived as a direct assault on the biomedical establishment. Other social symbols of authority are also being rejected. Hospitals are often accused of prolonging agony rather than renewing life. Body taboos do not seem to be as strong as they once were.
     These social changes strike at the heart of the meanings communicated by white coats. No new consensus has developed that will define the nature of healing and give direction for patient behavior. This has had an effect on the use of both white coats and examination gowns.
     The quote from Kriss (6) earlier in this paper that ex-pounded the significance of white coats is the result of widespread student challenges of the authority of this symbol. Debate over whether medical students should wear one still continues (34). Voices from some of the countercultural movements recognize the implications of this symbolism and reject it. Some feminists, for example, "advise women to discard the drape by throwing it on the floor when the doctor enters. If he replaces it, throw it on the floor again" (35). This type of symbolic action tends to make physicians uncomfortable, for the rejection of symbols of established roles means that there is little guidance as to how they or their patients should act.
     Cousins (36) comments on this redefinition of roles in the healing encounter when he claims that "the most important thing happening in American medicine today is not the discovery of magical new drugs but the new relationship that is emerging between physicians and patients" (36). The old model of the scientist-healer is rejected for a more humanistic relationship. He continues: "Traditionally the doctor is the authoritarian figure . . . the new relationship is more in the nature of a partnership." Note that the "traditional authoritarian figure" is, as has been documented here, a tradition that has only existed since the turn of the century. There were reasons for adopting that role at the time: there may be similar reasons for abandoning it now.
     The dynamic relationship that exists between physicians and American culture is only beginning to be explored. As we learn more about the social meaning and function of healing, we will better understand some of the conflicts that we feel between society and the profession. This in turn may enable us to devise better institutional and individual means of meeting these needs. But even before that global understanding is reached, there may be benefits that accrue on a smaller scale. In all patient-physician encounters, careful consideration of the symbolic and other nonverbal communication may be important. In particularly unsettled interactions, painstaking, explicit discussion and negotiation on the exact role that the patient and the physician will take may be required for healing to occur.


July 197 9 • Annals of Internal Medicine • Volume 9 1 • Number 1

ACKNOWLEDGMENTS: The author thanks his colleagues who read and commented on earlier drafts of this paper. Especially Pamela Amoss, Arthur Kleinman, Thomas lnui, and James LoGerfo, all from the University of Washington.

This work was supported by The Robert Wood. Johnson Clinical Scholars Program. The opinions expressed herein are those of the author and do not necessarily reflect those of The Robert Wood Johnson Foundation.

0. Requests for reprints should be addressed to Dan W. Blumhagen, M.D.; The Robert Wood Johnson Clinical Scholars Program. University of Washington, Varsity Apartments, HQ-I8, 3747 15th Avenue N.E.; Seattle, WA 9S195.

Received 5 September 1978• revision accepted 19 April 197R


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July 197 9 • Annals of Internal Medicine • Volume 9 1 • Number 1

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