The Whiter Coat

14 December 2014

            I hadn’t worn it in a year.  Halfway through internal medicine residency, I’ve lost two of my allotted four. But yesterday, for the Millions March in NYC, I donned my white coat under the banner of “White Coats for Black Lives,” over jeans, under scarf and knit hat. Doctors worldwide wear stethoscopes—a necessary tool, used for heart-lungs-belly-neck. A patient feels taken care of if you’ve listened to her heart and lungs. We have the laying on of hands and the laying on of stethoscope diaphragm and bell. Doctors worldwide wear white coats, a tool of nothing but repository for tools, a signifier of identification, power, an instrument of implementing hierarchy, and whatever else (including the positive) that is associated with the profession. With power comes implied responsibility, a mandate to earn the given trust.

            Before even my first day of medical school, we received our white coats in a ceremony, parents came and took pictures, and we solemnly recited the Hippocratic oath, months before touching our first patients. A symbol of induction into the lifelong guild. For students, the white coat is short, still symbolizing power to patients perhaps oblivious to the length, but clearly showing the lowest rank to other doctors. It takes so many years to arrive at medical school. We had made it. Quickly, I learned to hate the coat, resent it, except for its many practical pockets, and I relished the rotations—pediatrics and psychiatry—that didn’t require and even discouraged its use. In my social medicine program, there is something vaguely uncool about the white coat, the long white coat we worked so hard to achieve. I wore it for the protest, yesterday, faint ink marks still visible after hospital dry cleaning, in a contingent of many others---to show we know We are an institution, We are implicit and complicit, and We, in positions of power, are here in solidarity because, among other things, racism is bad for health.

            But to reject the whiteness of the coat requires whiteness, no need for cloth that soon shows sweat stains to confer that final privilege.
How are non-white-coated doctors of color seen in comparison to those in white coats? I’ve never thought or asked. It is the white doctors who can reclaim the coat in this particular era of protest (…partly because doctors are, still, majority white), to say fuck the institution, to say lie down, pretend to die, and fuck them, one minute of silence (eleven) for every “I can’t breathe.” Too, at a medical school, administration having heard vague rumblings of a coming protest, emailed a few vocal students of color to ask what was happening, assuming this issue and its demonstrations were divided by color lines. Elsewhere, faculty and administration were in visible support.

            Shortness of breath is a common chief complaint in offices and then ERs. The white-coated have algorithms memorized to diagnose and treat that. “I can’t breathe” generally means heart or lung. And for how long. Are the lungs closing up at any level (either no sound or whistles), or is the heart unable to move blood and thus oxygen through the body effectively, fluid backing up to legs (pitted like play dough), lungs (sound like crumpling tissue paper or the sound it makes if you pour milk over puffed rice), or the neck announcing every heart beat (anxious or arrogant in columns directed to the brain). History and physical lead to different paths, different etiologies, and different treatments. There is also the anatomic. If your chest wall is constrained and cannot move for force applied. If your neck is in a noose. This is easy to diagnose. You are unable to breathe.

            It takes privilege to reject privilege. And maybe in reality a black doctor should keep a white coat in his car in case he gets stopped at a non-roadblock, coupled with “MD” ID and stethoscope to toe past doubt. And maybe in reality a black med student should wear the coat at all times, because even in a tie he might be confused for any other worker.

            There is nothing inanimate about an institution. Medicine is not the prison-industrial complex. But in some places, a nurse is a warden is a prison medical director. In some places, doctors (docere, Latin, to teach) supervised executions. In every place in this country, pronouncing death requires doctors, as if anyone could not know by focused observation. If someone dies and no white-coated human passes by, did they really die?

            Each white coat is full of pockets, full of tools to fix things in theory. The four pillars of medicine are: Non-maleficence (do no harm), Beneficence (do good), Autonomy, and Justice. Too often, the fourth is missing. The injunction to save every life, regardless, is legacy from ancient Greece. It is so much harder to do good than to do no harm (in which we are often also paralyzed). Many times, it is not possible.

            After the protest, I removed my coat. I replaced it in my closet, haphazard and somewhat folded. At this rate, I’ll end residency with zero coats, but my next job will likely give me one the next step up, embroidered with my name. Sewn on and into privilege. White Coats for Black Lives is from Physicians for a National Health Program (PNHP): health care, equal access for all, health care as a human right. White Coats for Black Lives, because every doctor gets at least minutes to be white. I can reject the coat. I should not reject the privilege and power implied (earned and un-) to speak. We are given the coats from before the beginning. From this position, not just to the individual patients, we owe: Doing Good, Not Doing Harm, Respecting Autonomy, and Advocating and Fighting for Justice.

Jennifer Stella, MD