Whither the white coat and why

Whither the white coat and why

As a philosophical coda to the 2013 cacophony over Obamacare, health care reform and the notion that doctors and their skills will be needed less in some indeterminate future, this last month saw a media frenzy about the fate of the doctor’s white coat.

It started with an article by Gonzalo Bearman and his colleagues in Infection Control and Epidemiology that asked the question of whether the white coat might spread germs in the hospital. They concluded that we don’t know. But the idea lobbed about in the news was that doctors ought to wear short sleeves, another untested opinion that exposes the patient to more of the caregiver’s skin, a most common site for transmission of infection. Much ado, but the more interesting conversation is not this superficial.

This past August and September, 20,000 of the brightest, most accomplished students who have ever lived began medical school.  These students have already spent parts of their lives in worthy causes, they have excelled in school and standardized tests, and they are as idealistic as any who have preceded them. As much as the system can foretell, they are empathic, compassionate, respectful and expecting to change lives for the better.

During their orientation, and now some twenty years after the Arnold P. Gold Foundation brought the ritual to American medical schools, they don the healer’s habit. They participate in the white coat ceremony, where they receive their first white coat and recite an oath designed to remind them of the awesome responsibilities they carry, the central tenet of which is caring.  Many have predicted the end of the physician as we have known him and her, the end to the fictional Arrowsmith, Welby, Lockhart and Grey, and the importance of the empathic relationship between practitioner and patient that is literally thousands of years old.

Some believe in this century of biology we don’t need them, some that we can’t afford them, some that we physicians have broken irreparably the covenant that gives us privileges equal to the responsibilities. None of these is true. The new medical students know this and know as well that their professional lives will be very different from my generation’s, especially in their lowered expectations of wealth and elevated expectations of cure.

If Star Trek got it right, by 2371 doctors will have been replaced by infallible, always available, seemingly affable, algorithmically synthesized holograms. That future doc is known only as “Doctor,” the digital projection gaining in precision what Bones had in compassion. Its outcomes, perhaps even its care, will be scored by today’s incomplete and inadequate patient surveys as exceptional and it will receive the highest monetary bonus of the Physician Fee Schedule Value Modifier under Section 3007 of the Affordable Care Act of 2010. Yes, this is science fiction, but is it a dream we will await for another 350 years? When actually will the last medical student cloak herself in a white coat? In what year will the last human doctor die? Is the phantasm hologram or horror?

Hippocrates vs. Star Trek

There were answers in a revealing moment at a recent annual meeting of the organization that represents medical education in the U.S., the Association of American Medical Colleges, when the schedule juxtaposed talks by physician authors Eric Topol (The Creative Destruction of Medicine) and Abraham Verghese (Cutting for Stone). Topol is the director of the Scripps Translational Science Institute in La Jolla. A cardiologist, scientist and futurist, he borrowed from his book to describe a fantastic, optimistic future for health care in which the disruptive innovation of the digital universe changes the doctor — the system really — while improving the care.  Verghese is the senior associate chair for the theory & practice of medicine at Stanford. An internist, novelist and humanist clinician, he recounted how the order-the-test-first, talk-to-the-patient-later school of medicine leads to many of the woes of current acute care. He predicted a future in which health care is optimized by the disruptive innovation of Hippocrates, placing the patient at the center of the story and establishing a relationship of trust and safety.  So whose predictions are right? Incredibly, both are.

One of the outstanding descriptions of what health care reform must bring is the Institute for Healthcare Improvement’s “triple aim”– better care of the patient, better health for the population, and lower per capita costs. These can only be achieved by combining excellence in science with the highest compassion, contained in a digital system which links engaged patients with empathic, knowledgeable caregivers. One of the secrets known by those entering students is that twenty-first century care will be delivered by many kinds of professionals and so the humanism of the relationship must be extended from doctor-patient to system-patient. Anyone who speaks to, or touches a patient must be imbued with the healing traditions of the ancient art, and these can be taught by modern practitioners. The caring connection of practitioner to patient yields the triple aim: a better patient experience, better health outcomes at a lower cost, and the added benefit of supporting the practitioner to be more resilient and avoid burnout.

The rumors of the doctors’ demise are premature. In this country, there have never been as many people organized to figure out how to move the system away from the current dysfunction toward that triple aim, and the specialties are working together in new configurations that give hope to interprofessional training and care delivery. If you saw the faces of the class of 2017, after members of the faculty help them on with their white coats, transformed by the ritual and the oath and the sense of responsibility you would believe that they will fix what’s wrong. Even if we find they must wear airtight garments of special antibacterial fabrics imagined for the 24th century, the white coat with all that it means in the valuation of caring should still be donned by the newcomers to the new health care system.

Richard I. Levin is president and CEO, The Arnold P. Gold Foundation, emeritus professor of medicine, New York University and former Dean of Medicine, McGill University. 

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