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Presentation at the
White Coat Ceremony
University of Iowa
Roy J. and Lucille A. Carver College of Medicine
Friday August 22, 2003
Susan R. Johnson, M.D., M.S.Professor of Obstetrics & Gyynecology, and Epidemiology
Associate Dean for Faculty Affairs
President Skorton, Deans Robillard & Ephgrave, Mrs.
Katen-Bahensky, Dr. Helms; OSAC staff; faculty; students; families; ,
and friends --
It is an enormous privilege
to be invited to give these remarks, which I dedicate to my grandmother,
Ida Porter, who today is celebrating her 98th birthday -- she lives
independently in Lake City, Iowa, where I will be joining her and the
rest of my family tomorrow. Her long healthy life is in part a testament
to the advances of medical care in the 20th century (and to a set of
genes that I hope I have inherited!).
This is a wonderful day – and one that you and your family and friends have awaited for a long time.
My own wait began in the 4th
grade when I decided to be a doctor, and in fifth grade when I chose the
UI COM to attend. I changed my mind briefly in the first semester of
8th grade, but after that did not look back. After 3 years as an
undergraduate here, I entered medical school on a beautiful fall day
that I still remember clearly. The orientation then was brief; we were
the first class in the then brand new BSB, and there was no ceremony
I can’t help but remark on
one other difference: this year, I am told, the class is for the first
time equally divided between men and women; my class, the class of 1976,
was 9% women, and that was doubled from the previous year.
Why is the white coat such a
big deal? I am sure you are aware that the members of other health care
professions often wear white coats as well, so the coat itself is not
the thing that we celebrate today. And, it is not the person inside the
coat, at least, not merely the person. Rather, it is when the person in
the coat has the role of physician that the white coat becomes an
Unlike the symbols of some
professional groups, this symbolism is not something made up by and
promulgated within the profession -- rather, it is conferred by society
upon the medical profession, and so has more meaning.
I thought it would be useful
today to consider the underlying reasons that society has chosen,
throughout history, to confer special status on doctors, and then to
draw out some of the implications these ideas have for you, even now as
you are beginning your medical career.
Here is the general question: why do patients listen to their
doctors, usually believe and do what they say, and, why, despite
increasing complaints about the medical care system, does the public
continue to list physicians as among the most admired of professionals?
The theory of Aesculapian Authority is an attempt to answer these questions.
Aesculapius you know something about.
The definition of “Authority” that applies here is “power derived
from opinion, respect, or esteem; a claim to be believed or obeyed.
The theory was developed in 1957, not by a physician, but by an
organizational development expert, TT Paterson. He had already developed
a general theory of 5 different types of authority that support
different groups such as government officials, military leaders, etc. He
was then asked by a physician named Humphrey Osmond, a psychiatrist at
the University of Alabama, about what was the source of authority for
Paterson realized that he could not explain the authority of
physicians by any one of his categories, but rather by a combination of 3
of the types: sapiential, moral, and charismatic.
Sapiential means “having wisdom,” and so sapiential authority
refers to the power physicians have as a result of what they know. This
source of authority is obvious.
The scientific content of medicine is what attracted many of you to medicine in the first place.
(For me, in my 4th grade classroom was a book titled Huber the
Tuber. No, this was not about potatoes, but rather, about tuberculosis.
During WWII, the American Lung Association published this cartoon story
about the evil TB germs called tubers (cast in the story as Nazis) and
the immune system white blood cells (cast as the Allied forces) in a
battle for the lung. The purpose was to educate the public about TB --
but for me, it served as my introduction to pathophysiology and the
fascination of human disease.)
On Monday, you will begin the first of many years -- at least 7 --
formally learning an increasingly complex body of knowledge, and you
will need to learn continuously throughout your career in order to keep
your knowledge base up to date.
At my graduation from residency, our speaker, the late John Moyers,
former Head of Anesthesiology said something which I think about every
time I am tired, irritated, or distracted when seeing a patient: “When
your patient is in trouble, what he cares about most is that you are
The ubiquitous availability of medical research and opinion on the
internet has made our patients more informed, which is all to the good,
but has also has led some people to say that the physician’s authority
based on knowledge is eroding because medical knowledge can now be
accessed by anyone.
However, every practicing physician knows that “just the facts” is
not enough. It is rather the ability to integrate all these facts, and,
equally as important, to understand what you do NOT know, and to be able
to apply all this to the particular circumstances of the individual
patient sitting in front of you.
Moral authority derives from the principle that physicians are
expected to act not based on their own needs, but rather on behalf of
the needs and best interests of their patients. We are to act as leaders
to our patients, giving guidance not just mere advice - in fact, based
on our moral authority, we should act paternalistically, or parenterally
if you prefer. At first, this may appear to be at odds with the modern
emphasis on patient choice and autonomy, but it is not, as long as this
paternalism is tempered with respect for the patient’s choices and
A famous illustration of the need for moral authority is the story
of Franz Ingelfinger, most famous as long time editor of the NEJM, but
also an international expert on cancer of the esophagus, an aggressive
disease that is difficult to treat effectively. Berger, a Russian
psychiatrist, describes Ingelfinger’s dilemma when he himself developed
esophageal cancer: “One can hardly imagine a more informed patient than
him. After surgery, ... he received from physician friends throughout
the country a barrage of well-intended but totally contradictory advice.
As a result he and his physician family members became increasingly
confused and emotionally distraught. Until somebody wise said to him
“what you need, is a doctor.”
What did that mean? That what was needed was someone who could take
all the relevant medical facts, assess Dr. Ingelfinger’s individual
situation, and then advise and take responsibility for that advice.
Moral authority requires that the physicians work from a place of
personal integrity, not just in their work life but in their personal
life as well.
In the original meaning, charismatic authority derives from the
historical confluence between medicine and religion; between physicians
That combination may at first seem irrelevant, or even inappropriate, in these modern times.
In fact, it is both relevant and appropriate.
The modern basis of Charismatic Authority has nothing to do with
religion per se, but rather with the reality that life and death may be
on the line at any moment, and there is no way that any physician, or
even medical science, can know all that is relevant; thus, in a real
sense, the sick person must relate to the physician with faith, and the
belief that the physician can help. Beyond this, charismatic authority
leads many patients to bring issues to their doctors from all parts of
their life, not just their health -- think, for example, of how often
Ann Landers recommends to readers: “talk to your doctor” about problems
of all sorts.
This is an awesome responsibility -- and one that should lead the physician to feel, not arrogant, but humbled.
Every practitioner has had priest-like experiences -- it can be a
bit eerie the first time it happens, when you realize that people really
do see you as more than just a person providing medical care.
Here is a very small example from my own practice:
Just three weeks ago a woman, in her late 50’s and postmenopausal,
came to my clinic to review her laboratory tests. We had found a small
ovarian cyst several months ago, and I had ordered an ultrasound for
follow up to be sure it was stable, and thus unlikely to be cancerous.
The ultrasound actually showed that the cyst had gone away. When I saw
her name on the schedule that day, I thought, with irritation, “Why is
she coming in -- we could have done this by phone or with a letter. This
is a waste of my time.” I went to the room, and quickly told her the
good news that the test had been normal, and that no more tests were
She did not look particularly happy with this news, and then she
said, “ I need to tell you some things.” Over the next 15 minutes or so,
she went on to tell me that her husband had died of cancer 5 months
ago, her granddaughter was shortly thereafter diagnosed with a severe
psychiatric illness, and her brother had just developed advanced,
disabling chronic obstructive lung disease. She had no friends or family
to talk to, and she did not feel she could still be sad. She cried. I
listened. That was all she needed that day.
A characteristic you must develop to fulfill the mandate of
charismatic authority is empathy - not just for the patient’s illness,
but also for their whole being.
(subtitle): a brief poetic interlude
Twenty-four hours a day, seven days a week, and, I should have added, 365 days a year.
This is when you will be a doctor.
This is when the world will expect you to behave like a doctor.
This is when you may feel you need to be available as a doctor.
This is when you may want to stay in the role of a doctor.
Monday /12 am - diabetic ketoacidosis;
Tuesday / 3 am - motor vehicle accident;
Wednesday/ 10 pm emergency caesarean delivery;
Thursday / 2 pm in the middle of clinic, a cardiac arrest
Friday / 5:30 pm - a 3 year old child with acute otitis
Saturday / 1 pm - fourteen journals to read
Sunday - no day of rest
24/7: cures, needs, adrenaline, fatigue, “saves,” uncertainty, exhilaration, trouble, ... the truth.
First, you, the class of 2007.
Actually, not you as a class, but you as individuals. You - Melissa
Cervantes; You - Michael Friedman; You - LaKeesha Randolf; You - Nicky
Stoik; You -Ginny Harris; You - Todd Stevens; You – Hong-Phuc Tran --
and so on! We will listen to all your names in a few minutes.
At first glance it seems that it must require superhuman effort to
be a physician. But it does not -- it only requires your best human
In fact, it is those physicians who attempt to be superhuman who
often fail -- themselves, their families, and ultimately their patients.
In my roles as a collegiate administrator working with faculty, and as a
member of the Iowa Board of Medical Examiners I have seen first hand
the toll that this approach can take:
Some of you are saying to yourselves at this moment “STOP”- “What does this have to do with the excitement of today!
Everything, I think. Because now is the time to develop a life that is immune to these troubles.
For starters, here are three steps you can take to integrate your work life and personal life
It would take days to relate to you all the times I have not been perfect, but here are a few:
However, there is a second part to this last story. Three years
ago, almost 20 years after that event, I was listening to a second year
medical student present the case of a patient he had worked up as part
of the 3rd semester Patient Centered Learning course. All of a sudden,
while listening to the past medical history, I realized that it must be
this same woman. Imagine, then, if you were I, and heard the student say
next: “and ever since the perforation, she has not trusted any doctor.”
Mistakes are inevitable, not discussed during training or in
practice often enough, and sometimes they do have long-term consequences
for the patient. However, mistakes learned from ultimately make you
better, in fact, as much as you should try to prevent them, in some
sense, you must also welcome them.... and find a healthy way to deal
with the emotional aftermath.
“Resilience is the ability to bounce back after being
psychologically stressed,” say Mary and Wayne Sotile, psychologists at
Wake Forest University School of Medicine, and authors of the book The
Resilience is a key factor in job and life satisfaction -- and so is well worth developing.
The Sotiles describe numerous strategies to help physicians do just
that -- such as using your stress related symptoms as a signal to
change the next step in your usual coping process to something more
healthy; re-frame the way you think about change, from a negative to an
opportunity; learn to be optimistic; etc . I encourage you all to read
the book someday.
But for now, I want to mention a particular problem the Sotiles have identified among medical students and residents:
Addressing practicing physicians about this time in training, they say:
“Along the way of your medical training, you probably became
proficient at self-denial -- ignoring your feelings, your appetites, and
your own needs -- in order to get your job done and provide whatever is
asked of you. Perhaps you entered medical school already prone to
please others, even at your own expense. If not, you soon learned that
doing so was a survival skill that allowed you to meet the extraordinary
demands of medical training ... [But] when ...you repress awareness of
your own needs and feelings and rely too much on your ability to delay
gratification as you work to gain approval from others, the result can
be a life of struggling... The paradox: The very coping skills learned
in your efforts to become a good caretaker serve to stress not only
yourself but those around you.”
To counter this problem:
The number one factor enhancing satisfaction in most surveys, which
will come as no surprise, is having developed “A personal sense of
In a recent study by Horowitz, the other factors identified had to
do not with the achievement of spectacular cures, or technological
wizardry, but rather, with the development of relationship to patients
There are other “you’s” here today: administrators, faculty, family and friends:
You each have a role to play in helping these students achieve
these goals of dealing with mistakes and uncertainly, improving
resiliency, and developing relationships with patients.
I hope you will take this responsibility seriously.
The factor identified in the Horowitz study “a fundamental change
in the doctor’s perspective” referred to the physician’s having sudden
insight about herself or her attitudes during a particular, often
problematic, patient encounter - and usually these led to increased
awareness of patients as fellow human beings.
I can’t assign you to see patients just yet; but in the meantime,
here is an exercise that can lead you in the direction of that same
The objective of this assignment is, in the words of Horwitz, to
expand the boundaries of your role as scientifically detached observers
and prescribers of tests and treatments ... (to) recognize (your)
patients as fellow human beings, rather than objects of care.”
Here are the instructions:
Go to the hospital lobby --( But don't all go at once!) or, you can
do this at the Coral Ridge mall, the O’Hare airport, or a even a
Hawkeye football game.... anywhere there is large crowd of “real”
Look at each person you see - carefully (but without staring!) and say to yourself:
Do this for 20 minutes, every once and a while.
There are few professions as fascinating, challenging, and as
rewarding, as medicine. Today, on behalf of all your future teachers, I
welcome you as you start on the road to a life of medicine, and I wish
you to be well on that journey.
Berger M: Chronically diseased patients and their doctors (in Russian).
Tschelowek [Moscow] 9 (4):119-125, 1998 (available on the web at
Horowitz CR. Suchman AL. Branch WT Jr. Frankel RM. What do doctors
find meaningful about their work? Annals of Internal Medicine.
Osmond H. God and the doctor. New England Journal of Medicine. 302(10):555-8, 1980
Paterson, Thomas T. Management Theory. London: Business Publications, 1961
Sotile, W and Sotile, M. The Resilient Physician: Effective
Emotional Management for Doctors and Their Medical Organizations.
American Medical Association; (January 2002)
Wilmer, Harry A. Huber the Tuber: Lives and Loves of a Tubercle
Bacillus, New York, N.Y.: National Tuberculosis Association, 1942
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