MD Program

  • Inside the White Coat

    Presentation at the
    White Coat Ceremony
    University of Iowa
    Roy J. and Lucille A. Carver College of Medicine

    Friday August 22, 2008

    Rebecca Hegeman, M.D.
    Clinical Associate Professor, Department of Internal Medicine

    Thank you to the members of the Gold Humanism Society who invited me to speak today and to Dr. Cooper for his kind introduction.  It is an honor and pleasure to be here today. 

    I would like to extend a warm welcome to all of you, the first year medical students, and your family and friends.  We are really excited to have you here in our program.  We think Iowa is a great place to train and are confident that we will convince you of that as well.  You happen to be starting your first year of medical school after a very eventful summer at the University of Iowa.  Because of the flooding we had to move this ceremony from Clapp Hall by the river to MacBride Hall.  Being here takes me back to the Zoology class that I took in this very room 26 years ago, sitting up in the balcony.  I was a nurse when I decided to return to school with the idea of going to medical school.  In this room, Dr. Frankel, a legend in the University of Iowa premed curriculum, taught the zoology class.  I remember this class because of the difficulty of his examinations.  Memorizing your notes did not help with the exam – you had to understand the content.  You were required to apply problem solving skills to new problems.  This is exactly what happens with patient care as they don’t always behave like the textbooks say they will, so these zoology tests turned out to be great preparation for the years to come. 

    You will be donning your white coats today in a ceremony that emphasizes our confidence in your ability to become a compassionate and knowledgeable physician.  I suspect that some of you are sitting there wondering if you deserve that confidence, and I want to assure you that you do.  The white coat has been a symbol of the medical profession for many years and has been said to represent “goodness” and connote a “purging of infection”.  In a few minutes Dr. Cooper will elaborate further on the meaning of the white coat.  Right now I would like to focus on the person inside the white coat and make it somewhat personal, describing what the white coat means to me.  It is important to note, that each you will decide for yourself what the symbol of the white coat means to you and how you will convey this to patients and society.

    I am a nephrologist and take care of patients with kidney failure.  Several years ago I met a young man who had just received a bone marrow transplant for a cancer.  This young man’s story has been published in the newspaper and some of you may have read about him.  After the transplant, he acquired a severe infection due to his immunosuppressed state.  In the process of treatment he developed kidney failure that required dialysis.  He was in the hospital for several months and there were many times when I was sure he would not make it.  Amazingly enough he eventually recovered from his infection such that he could go home.  He still couldn’t eat and had to receive his nutrition intravenously.  He was very hard of hearing because of the drugs necessary to treat his infection and prevent him from dying, and he still had kidney failure, but he was home and very much alive neurologically.  Over the next 3-4 years, he received chronic dialysis as an outpatient three times a week.  As it happened I met up with him again when he was transferred to my shift of dialysis patients during this time.  His strength gradually improved and he went back to work (his wife and friends kept the business going when he was ill).  He eventually received a kidney transplant and a cochlear implant and is now actively running his business and helping his wife raise their family. 

    So why did this young man make it against many odds?  When I googled “white coat ceremony”, I discovered that some individuals think that the white coat promotes elitism and separates the physician from the lay person carrying a negative connotation.  Well, I believe this young man made it because there was a team of “white coats”, a team of health care providers working together with a common goal to improve the patient’s outcome.  This young man required the services of numerous physician specialists, nurses, dietitians, physical therapists, pharmacists, research scientists, clerks to name but a few over a prolonged period of time.  The white coat does not give you a license to be the boss or dictator or to set yourself above everyone else.  What it does is entitle you to be part of a team, to be a “team player” if you will.  It is absolutely crucial to being a successful care giver these days.  You must be able to communicate and work with other physicians from various specialties, to work through your differences in opinion and you must be able to work with other members of the health care team noted above, in order to achieve the best for the patient.  You cannot do it all by yourself.  Many times you will be the director of the team, and developing leadership skills is a very important part of accepting the responsibilities associated with the white coat you are receiving today, but you need others to help you.  They will bring expertise, support, controversy and fun to the table.  As part of the team effort for this patient above and as we do for all chronic dialysis patients, the dialysis nurse, social worker, dietician and I met once a month to discuss the various aspects of his care.  It is amazing what you can learn from the dietician about why a patient is not following your instructions at home, for example which patients eat beef jerky with 1000 mg of sodium per piece and which ones don’t.  If you work with your team, these people will share responsibility for the successes with you, but also the failures.  They will make suggestions for improvements and support your actions, if appropriate.

    I’m sure some of you are ahead of me in thinking, “what about the patient?”.  Yes, the patient is the most important member of the team, as are families.  Patients must be involved in the decisions about their care or you will not be successful.  In the above example, I am absolutely certain that this young man would not have made it no matter what the healthcare team did, without the advocacy of his wife and his persistence.  She was amazing as well, looking out for him all the time.  I recently spent some time in the pediatric ICU as a nephrologist and I was impressed by the fact that the teams rounded in the patient rooms with the parents present instead of talking outside the room.  I can’t tell you how many times a plan for patient care has been developed only to be derailed by something as simple as “I can’t get a ride at that time”. 

    Sometimes patients and their families will look to you, the person in the white coat, to make the decisions for them.  They simply cannot comprehend everything they are being asked to digest, especially if time is short.  At my son’s college graduation a few years ago the speaker talked about “using the knowledge that you have earned here to find ways, not only to connect to computers, but to connect people; not only to bridge gaps in science, but to bridge gaps between cultures . . .” and so forth.  The white coat is a symbol of an educational process that will continue over the remainder of your life.  Use it to translate difficult concepts and teach patients and others so they can make informed decisions with your assistance.  

    I would like to be able to tell you that wearing a white coat and applying the above team concepts means you will always give superb care and have outcomes like the young man had above.  Of course, that’s impossible.  We are all human.  It can be very painful to be part of a process that does not lead to a good outcome for a person.  I am sure that all of us sitting up here today can think of more than one instance when the patient outcome was not what we had hoped.  Know that you will not always choose the best course of action.  It may be due to lack of knowledge, lack of communication, time factors, unknown patient factors or other unknowns.  But don’t let the white coat keep you from acknowledging a job not so well done.  Use it to encourage collaboration and stimulate learning about what could make things better in the next case.  Forge relationships with others who can help you, be they other physicians or other members of the health care team.  I can tell you from personal experience that these are times when it is especially nice to have a team to support you.

    Some of you may choose to abandon your white coats based on your future practice settings – it may be impractical or just “not you”.  Does this mean you have abandoned the ideals behind the white coat – of course not.  The person inside the white coat is still there.  I encourage each of you to think about the symbolic meaning of the white coat and how you are going to fulfill the commitments that are behind the symbol, with or without the white coat.  You all bring with you a variety of experiences and perspectives which are so important for the future of healthcare.  Inside the white coat will be different persons with different knowledge bases, different strengths and different goals.  This is so important for the future of healthcare if we are to serve all individuals.  I encourage all of you to think about this as you develop the person inside your white coat.

    So I asked my younger sister who went to medical school later in life, what she remembered about her white coat ceremony speech a few years ago and she said “nothing”.  This discouraged me a bit, but I decided I am going to give you the answer or ask you to remember one word in case your relatives ask you what I talked about today or in case Dr. Frankel is waiting in the hallway out there as you walk out the door– it’s TEAMWORK.  Your white coat entitles you to be part of a great team of health care providers whose goal is to provide superb care for everyone.  I look forward to meeting and working with you in the classroom and on the wards over the next few years as we all work towards this goal.  It’s an exciting time, and I wish you the best.