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Presentation at the
White Coat Ceremony
University of Iowa
Roy J. and Lucille A. Carver College of Medicine
Friday August 19, 2005
Paul A. James
Professor and Head, Department of Family Medicine
Thank you Dr. Ephgrave. Dean Robillard, Mrs. Katen-Bahensky,
Provost Hogan, colleagues, future physicians, families and friends, I am
sincerely grateful for the opportunity to share this day with you.
I can hardly contain my enthusiasm for you because you have chosen
the greatest profession. I feel your excitement and understand well your
thirst for knowledge. And on Monday, Dean Robillard will open the
floodgates of knowledge, and a wave of information will not only quench
your thirst, but will perhaps have you searching for a life boat.
Each of you is here today because of unique circumstances and they
relate (I hope) to your desire to help someone in need. Not to frighten
anyone, but think about it, at this moment, there is an individual out
there, who is on a course that will intersect with your life. This
person will call you doctor and will come to you with the expectation of
healing. That person’s story has begun, and you will become part of it.
Later, you will recite the Hippocratic Oath and you will “swear by
that which you hold most sacred”. Now that sounds like serious business.
Sacred is a difficult word in today’s lexicon signifying, depending on
your world view, something very important to be treated with respect, or
something to reverence signifying oneness with God, holiness. When one
deals in life and death, sacred becomes an important word.
It was 25 years this week when I walked your path, and I have
decided to provide you glimpses into the profession of medicine and
these sacred moments. I will share with you the doctor’s perspective,
but I also hope that you see a very human perspective in three stories.
Like the poet Muriel Rukeyser, I have the suspicion that “the universe
is made of stories, not of atoms.” These experiences represent lessons
that honor the purpose of the White Coat Ceremony. They are to teach you
about the importance of humility, hope and something stronger than
death itself, the healing power of love. Perhaps you already know these
things, but I want you to experience them as a physician with me guiding
you in this protected place. Imagine then, that you wear the white coat
of the healer.
I wanted this story to be about humility, but it’s really about
physician hubris- my own inflated sense of what being a physician meant.
I was completing my second year of residency, finally becoming
confident in my knowledge and skills. I was on call that evening and had
just returned from the emergency room at about 11 p.m. I was now taking
call from home and it was wonderful. I was awakened a little after
midnight by my pager. I dialed the offending phone number.
A lady answered the phone and was somewhat frantic in her request
that I come to her home and make a house call on her husband. She
relayed to me that he had a fever of 104 degrees, was clammy, having
difficulty breathing and “making gurgling noises.” My mind raced through
the differential diagnosis. I surmised that this man was sick.
“It sounds like your husband is very ill, he could even die,” I
said. “You'll need to take him to the emergency room and I will meet you
“No,” she replied. “I need a doctor to come to our home.”
I felt resistance to my generous recommendation. She clearly did
not understand that I was the physician. This pushback caused me to
question her motives. My mind raced to other questions and
possibilities. Why was she so accepting of the possibility that her
husband might die? This lady's voice sounded young, perhaps in her 30s
or 40s. A man who is gurgling certainly must be in his 80s. Perhaps this
was a May-December marriage, and she married him for his money. The
headlines would read, “Widow Inherits Millions with the aid of a young
I really couldn’t hear her explanations for why she thought I
should come to her home, because of my preoccupation and frustration
with her inability to listen.
“So, Dr. James, will you now come to see my husband?” she asked as my attention returned to the phone call.
Now I was definitely worrying about me. What will my colleagues say
if I make a house call on a deathly ill gentleman? How will I explain
this to my attending staff in the morning? I'll be the laughing stock of
I returned to the matter at hand. Perhaps I needed more history. I
reiterated to her that it sounded like her husband might die. Was she
really willing to accept that he might die at home?
“Well, yes,” she said, “of course.”
I regained my sanity and returned to the basics. Her husband was 43
years old. He had multiple sclerosis and had been hospitalized too many
times to count. Four months ago, he made his wife promise that she
would never take him back to the hospital.
“Dr. James, do you understand that I need you to come see him because I'm very worried about him,” she reiterated.
I went to the home, scared to death. Upon entrance to the small
home, I noticed the patient over on the right side of the living room in
a hospital bed. He was diaphoretic, pulse was 120 and his temperature
was indeed 104 degrees. His lungs were terribly congested with rales on
both sides half way up the chest. An indwelling Foley catheter showed
that his urine was very cloudy. I finished my exam, noting how the
patient had no evidence of skin breakdown, his skin care the best I had
seen for a bedridden patient.
This gentleman had the clinical signs of sepsis. My struggles over
the next few hours were to learn how to get labs, antibiotics and IV
fluids from a University hospital. I told his wife that I would draw
blood cultures and other blood test. As I was drawing blood, she asked
me if it would help to have a sputum sample. I responded that it would
be wonderful but I did not think the patient could cough anything up in
his weakened condition. She told me that she would get the sputum for me
and performed deep endotracheal suctioning. I recognized at that moment
that this gentleman was perhaps far wiser than I suspected with
wonderful care like this in his home.
The following day I heard good reports from my colleagues that he
was responding to the intravenous fluids and antibiotics that I had
started the evening before.
I learned a valuable lesson- in order to listen to patients and
understand their goals; I would need to empty myself of my
preconceptions. Humility is your greatest ally as you attempt to listen
to your patients. Humility is not a product from thinking poorly of
oneself, but of thinking highly of others - value patients and their
Humility is important to our humanity, but also hope is important.
You may not be aware of the hope you bring as a physician, but follow me
into another night, five years later. Students, remember that when you
wear the white coat, expectations can sometimes seem too great.
It is a Friday night and I’m now the family doctor in a small-town.
It had been a busy week and I was tired. My brother convinced me to go
to the high school football game with him since I was the team
physician, but the cold rain of that November night made this outing
We were a couple of miles from the school along a dark stretch of
wet rural road, when we came upon the bright flashing lights of rescue
vehicles and Highway patrol indicating an accident ahead. My brother
pulled over and jumped out of the car. I sat there, tired. I comforted
myself with the notion that EMTs are well trained for emergencies such
as this. What could I really do all sopping wet?
I saw the highway patrolman return to his car in front of me, so I stepped out to ask him a question.
He recognized me immediately, calling me by name and hurriedly told
me that they needed my assistance. A 16 year-old high school student
had turned onto the highway from his driveway and was struck head-on by a
drunk driver. He was trapped in the wreckage. I surmised the other
driver was already on his way to the hospital but did not really grasp
what lay before me in the cold rain.
I stepped into the bright lights and a second later, I heard a
voice whisper to a distraught mother and father, “Its okay, Dr. James is
It was not okay. Despite my anger at this person for making such a
hopeful statement in such a desperate situation, I focused on the tasks
at hand. ABC's, that's it - airway, breathing and circulation. I was
pleased that the young man could respond to my questions and that gave
me hope. The technician was fumbling to get IV access and was poking
everywhere except in the vein. I held his hand steady, pushed the
catheter a little, and he was in. He smiled at me.
OK: Intravenous fluids are running, the patient is responding
verbally. Within the next few moments, the “jaws of life” finally did
their work and the young man was released. I was somewhat surprised when
everyone at the scene demanded that I ride with the young man to the
Despite serious injuries, the young man lived. Everywhere I went in
town; there were pleasant smiles and knowing glances of appreciation
for the fine young doctor in the community who heroically saved that
student from death. However, I felt guilty about this undue adulation. I
was even a reluctant volunteer. Really, I adjusted one technician’s
intravenous attempt. I did not want the community to have unrealistic
expectations, that’s the recipe for disaster. I suspected the source of
this misinformation was the mother of the student and resolved to speak
to her. I would explain to her that chance was the reason that her son
had lived - not me.
She asked me what I knew of chance. Is that like being lucky, or
unlucky? My whole notion was absurd to her. There was no chance like
that in her world. She had seen her son at the brink of death. She knew
about chance. In fact, that's what she prayed for. She and her husband
had prayed in those moments before my arrival that their son might have a
chance to live- they knew that their son would fight hard if given the
opportunity to be under the care of a knowledgeable physician. Their
prayer had been answered. If their son had that chance, they could
accept his death because everything possible would have been done.
The mother then explained to me her view of what happened that
night. She had seen the despair and hopelessness of those trying to help
her son. She had even felt that same despair herself. But with the
arrival of the physician, the one person in the community with training,
knowledge and skill, came hope. And while I may not have been aware of
how others responded including her son, she was.
The physician gave hope in the midst of suffering even though he
thought he could do nothing. Sometimes, it is enough simply for the
physician to be the splint that holds a fractured life.
**This mother and father did all they knew to do for their child.
That is what people do for those that they love. Your patients will want
to know from you whether they did all that they could. Your patients
will expect the same from you.
We have seen the importance of humility for physicians, and how
they provide hope. Now let’s return to finish the initial story of the
gentleman who was very ill at home and learn how families deal with
The Final Story: Honoring Relationships
Three nights later I was paged at 4 a.m. and dialed the vaguely
familiar number. The wife answered the phone and this time, was equally
“Dr. James, thank God it's you.” She said. “I think my husband is dying. I don't know what to do. Can you help me?”
This time, I did not do an inquisition. I hurried to her home and
entered the doorway. I looked over at her husband who was eerily still
with no respirations. I stepped over to him mostly thinking of what I
would say to his wife. What was appropriate?
“Tell me what happened,” I asked. She responded, giving me time to think.
She told me about all that she had tried to do in the last few
hours to sustain her husband. Would my pronouncement in some sense be a
judgment on her actions and relationship with her husband? Was her
husband's death a defeat for both her and me? Did I share in this
“I think you did all you could. No, we did all we could. We tried
to abide by your husband's wishes. I believe that he would be very proud
of you and what you did for him,” I said.
The next hour I attempted to find a mortician who would accept
credit because of their financial situation. In that time, I found out 4
months ago, her husband had paid off the mortgage with his disability
income and felt he had done all he could. I stood up to leave but as I
did, she broke into tears.
“Dr. James, you've helped me some much. But my biggest concern now is about my son.”
“What do you mean?” I inquired.
Her son was 13 years old and sleeping in the bedroom adjacent to the living room.
“Should I awaken my son and allow him to visit with his father before the mortician arrives?” She asked.
She and I together entered the room and visited with her son. I
asked him about his father and their relationship. He told me of his
nightly prayers- that God would accept his father into heaven soon. He
knew that this was what his father wanted. Yes, he did want to visit
with his father. I witnessed at 5:30 a.m. that morning, a son and his
mother, holding a departed father and husband in an embrace that was
Two days later, I read an obituary of a 43 year old pharmacist. It
said how he was loved by a devoted son and wife. And I, the physician,
knew in greater depth the truth of that sentimental statement.
I’ve shared with you some of my intimate moments as a physician.
While wearing the white coat, you must balance the pride of
accomplishments with humility, hope with realism, and understand that
death, though it is often framed as our worthy enemy, is one step in the
cycle of life where a family’s love can have immeasurable power. So,
how does one find meaning in medicine?
Dr. Victor Frankel in his book, In Search of Meaning, describes three avenues by which one may find meaning in life.
So now we return to your sacred oath. I have shared with you three
of my sacred moments where I learned the power of humility, hope and the
defeat of death by a family’s love. In each case, my inspiration for
practicing medicine was strengthened, not weakened. Like Victor Frankel,
you have a choice; to become cynical and bitter practitioners of a
well-paid profession, concerned mostly with your own well being, or to
reach out and share your knowledge, skill, but always to act as a caring
and compassionate physician.
To keep my own perspective, I often submit a brief prayer
especially when I’m not at my best, to acknowledge my very small role in
this world, and I invite God to join me in a sacred moment. In doing
so, I am more able to be a vessel of humility and hope, while honoring
the loving relationships that my patients have spent a lifetime to
My challenge to you is that you will identify suffering and that
you will be moved to act with care and compassion for those in need. Now
you begin your stories, I invite each of you to one day share them with
me. May God bless you all.
Viktor E. Frankel, Man’s Search for Meaning: An Introduction to
Logotherapy. Printed by Beacon Press, 25 Beacon Street, Boston,
Massachusetts. Original publication in 1959. 4th Edition published in
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