Keep Your White Coat Thin: A Message to First-Year Medical Students
Bruce H. Campbell, MD, FACS
Professor, Department of Otolaryngology and Communication Sciences
Professor, Institute for Health and Equity (Bioethics and Medical Humanities)
Medical College of Wisconsin
MCW White Coat Lecture - August 2, 2024
American Family Field - Milwaukee, WI
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I completed my otolaryngology residency in the early 1980s. One day, while working in the ENT Clinic in the old Milwaukee County Hospital, I walked into an exam room to meet my new patient, a 90-year-old man with a broad smile, a firm handshake, and a generous mustache. He lived in one of Milwaukee’s ethnic working-class neighborhoods and had spent decades toiling away in a noisy manufacturing plant. The effects of age and his long-term noise-exposure left him with a very severe nerve deafness. He was in clinic to follow-up on his hearing test.
I launched into an explanation of the test results, but he cut me off.
“You must look directly at me and speak loudly, young man!” He shouted. He could barely hear his own voice.
I started over. After reviewing the audiogram, I told him he would benefit from hearing aids.
“Young man, how much would such devices cost, do you think?”
At that time, a decent set cost almost $800.
“Oh, Doctor!” he said. “That is too much! I live on social security and a small pension! How would I ever pay for such a thing?”
It was a serious problem but, in his case, I had an idea. I asked if he had ever been in the military.
“Oh, yes, Doctor! I was in the infantry during The Great War! What an experience that was! We marched clear across Europe!”
His military service was good news. I had just completed a rotation at the VA where I had cared for several World War I Vets. Although the rules were different for Soldiers who served in later conflicts, the VA provided hearing aids to all World War I Veterans regardless of how they had lost their hearing. There would be some paperwork, of course, but I could help him get plugged into the system.
“Hang on a few minutes while I make a couple calls.”
I got up to go call find a phone.
After a couple of seconds, he held up his hand. “Doctor…” he shouted.
I turned back to look at him.
“Doctor, no…”
“What is it, Mr. Schmidt?”
“No, Doctor. This won’t work, I am quite certain they will not give me hearing aids at the VA.”
“Of course they will! I know these people and they will be glad to help you Your service makes you eligible!”
“Doctor, listen to me!” he shouted. “During the War, I was on the wrong side!”
Ah. So, what had I done wrong? I had not listened to his entire story.
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Over the next few minutes, I will share with you the importance of listening to stories, both as a medical student and as a physician. Your peers’ stories. Your patients’ stories. Your own stories. And the story of you and your new white coat.
To my mind, the White Coat Ceremony is really a commencement exercise. Accepting the coat tells the rest of us that you believe you are ready to commence your journey. Not to stretch the analogy too far but you are now a protagonist in a mythic Hero’s Journey heading out on your quest. At some point in your life, you heard a Call and you responded. You became the next Ulysses or Luke Skywalker or Frodo or Katniss or Harry Potter. It has taken some of you a long time to get to this point but, now, here you are, ready to take the plunge. Like all heroes in epic tales, you will soon encounter unknowable trials, surprises, challenges, and rewards. Along the way, you will encounter mentors, guardians, allies, antagonists, and tricksters. The journey will change you and define you for the rest of your life. The white coat is a visible sign that signals you are on the threshold passing from your old, known world to the mysterious world of medicine. So, on your mark, get set, go!
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My classmates and I received our first white coats in 1976, long before the transformation of medical education. My career was bookended by the emergence of the HIV/AIDS crisis at the beginning and the lifting of COVID-19 restrictions at the end. When I started, people did not learn about their diagnoses on Google or explore treatment options on X. I cannot predict what the future holds for you, but I can guarantee change, challenges, and upheaval. Still—and despite everything that has happened to healthcare over the past half-century—I loved my journey and would sign up all over again.
Along the way, there were two simple things I did every day to remind me of why I went into medicine in the first place: First, I tried to focus intensely on each patient’s story. And second, I tried to accompany each patient on their illness journey.
So, focusing on the story. Listening intently is not as easy or as natural as it sounds. Studies show that physicians routinely interrupt patients and take over the conversation within fifteen seconds after the start of any clinical encounter. But if you master the art of truly listening–and listening radically and generously–you will be a more effective physician. I eventually learned my German Veteran’s story, but it took me a while.
And accompanying patients on the journey. If you master the ability to intentionally accompany those who are suffering, you will not only help your patients, but you will sustain your own wholeness, maintain your empathy, and be a compassionate, caring healer. And, yes, I did eventually find a way to get the gentleman a discounted hearing aid.
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Here’s a story of a patient who taught me the value of accompanying people on their journeys:
I spent my career as a head and neck cancer surgeon. Years ago, I cared for an older woman who had a recurrent tongue cancer. As her cancer progressed, I had little to offer surgically. She decided to have no more treatment.
Still, she insisted on frequent clinic appointments. Every couple of weeks, she was back for a recheck. Each visit included a story or two, a question about her dressings, an update on her children, her anxiety about something she had read in the morning paper, and the same question—asked a dozen ways—about her prognosis.
I felt pretty useless. We covered the same territory each time. I usually made a couple of suggestions and wrote a prescription. Then, two weeks later, she would be back. She had taken none of my suggestions and filled none of the prescriptions. She shrugged and smiled, “I guess I just like coming in to talk.”
After a few months of these seemingly unnecessary visits, she died. At her visitation, her husband thanked me profusely. Each visit had been the highlight of her week. Our time together revitalized her and gave her hope. I told him I had loved the visits, as well.
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Many of you arrive here with at MCW with backgrounds in biology, biochemistry, engineering, or physics. Like your peers, maybe you weren’t drawn to literature, the humanities, or the creative arts. Why might engaging with stories and promising to accompany each person on their journey make you a better medical student and physician?
Think of it this way: you currently consider yourself to be “normal.” You are altruistic, compassionate, hard-working, and dedicated. At this point in your life, studies show that your “vicarious empathy”—your ability to viscerally experience someone else’s loss, pain, or suffering—is at the same level as it is for the non-medical lay public.
However, a study measured changes in the vicarious empathy of medical students. Would you like to guess what happened as the students progressed through school? Vicarious empathy scores dropped steadily through the four years, particularly during the first and third years. Even though the students knew they were being monitored for empathy, their scores plummeted.
Why? Well, not to ruin the surprise, but your life is about to change dramatically. As medical students, you will be confronted with hundreds of previously unencountered situations and have little if any time for reflection. For example:
Your academic workload will be overwhelming.
In a few weeks, you will hold someone else’s heart and brain in your gloved hands.
You will be present when other human beings hear terrible news and experience profound loss.
Someone you know will die. And it will happen again and again.
Other human beings will expect you to probe their bodies, review their symptoms, search them for cancer, interpret their test results, and then explain what it all means.
You will repair cuts, give shots, start IV’s, plunge in knife blades, slide in catheters, listen for murmurs, share bad news, deliver babies, treat the ungrateful and combative, sense the pulsation of aortic aneurysms, recoil from the odor of abscesses, and feel the warmth of the abdominal contents enveloping your forearm.
These rapid-fire experiences come and go with little warning. If they shock you, they will impact your vicarious empathy. In a perfect world, whenever one of these seminal moments occurred, we would reconvene here, reflect, and hold another ceremony. Instead, these experiences pile up and create layer upon layer of insulation. They threaten to harden and “protect” you from your emotions and your sense of humanity.
During each high-impact moment, you will look around. If everyone else in your line of sight seems to be shrugging their shoulders and moving on, you will see that as “normal.” So, what will you do? Your easiest path forward is to mistakenly believe that no one else is feeling what you are feeling, so you shrug and move on, as well. And, with each of these moments, your vicarious empathy takes a hit. In a “death by a thousand cuts” kind of way, it impacts your character and your willingness to care. And, don’t forget, you will soon be the role models for the students right behind you.
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I have never met a first-year medical student who aspired to be an arrogant, self-absorbed, money-grubbing, egomaniacal, golf-obsessed, pompous, narcissist. No one ever sets their sights on becoming a condescending doctor who interrupts patients, denigrates colleagues, ignores students, and insults nurses and pharmacists. But, by golly, sometimes that happens. Might there be elements of truth in Scrubs, Grey’s Anatomy, or House?
How do you prevent becoming that kind of doctor? I don’t know exactly, but looking beyond each patient’s chief complaint and working to see the life narrative in which that suffering is occurring is a good place to start. I have done my best work, both inside and outside of medicine, when I attempted to understand each person’s current situation within the context of their own Hero’s Journey. Teasing out that story takes time, of course, but it is well worth the effort.
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Here is my plea: Every time you put on your white coat, remember that patients are more than the medical problem for which you are seeing them. Over the next 45 years or so, you will repeatedly face the dilemma of whether to do the hard work of engaging with their stories and accompanying them or else defaulting back to whatever it takes to check a box and generate a billing code.
So, as you begin your journey, here are four strategies to help maintain the level of empathy you now possess.
First, keep being creative. Be aware of the challenges you and your empathy are facing and realize that creativity helps you maintain your humanity. Keep a journal. Set aside time for the things you love to do, be it music, art, writing, poetry, yoga, swimming, running, or kickboxing. Sir William Osler once noted: “While medicine is to be your vocation or calling, see to it that you have also an avocation—...No [one] is really happy or safe without a hobby.” Keep your creative juices flowing. They tie you to the outside world.
Second, listen to your friends and family. Share your own stories with them. Don’t lose touch with people who make you a better person. If the people who know you best and can help you maintain your balance are in the stadium today, make eye contact right now and promise to listen to what they tell you about yourselves. Seek out honest and loving guides.
Third, value your mentors and role models. If you are an introvert, fight the temptation to try to go-it-alone. If you know someone who is making a difference in the world, cling to them. Seek out and spend time with role models from the past and present. Read books by physician-writers such as Anton Chekhov, William Carlos Williams, Lewis Thomas, Oliver Sacks, Danielle Ofri, Richard Selzer, Abraham Verghese, Atul Gawande, Siddhartha Mukherjee, Damon Tweedy, Paul Farmer, and Paul Kalanithi; books brimming with stories and insight.
So – First, keep being creative. Second, listen to your friends and family. Third, value your mentors and role models.
And finally, keep your white coat thin. Over the next four years, your coat will be laundered many times. Hopefully. With each trip through the washer and dryer, the fabric becomes a bit more porous. Let that be a metaphor. Although your white coat is designed to protect your clothes, it is not meant to be a suit of armor. It does not represent membership in some exclusive club. It is not a shield to protect you from suffering. It certainly does not set you apart from the rest of the world.
Society has entrusted you with the white coat. We don’t expect you to fix everything, but we ask you to wear it while running toward crises and doing your best to heal the world.
Your coat should be thin enough to allow stories to pass both ways. Let other people’s stories penetrate and profoundly affect you. Don’t interrupt. Listen intently. Be astonished as you sit with families at the most critical and even mundane junctures of their lives. Listen and respond with all the empathy you can muster. Pledge to accompany each of your patients because they, just like you, are somewhere along the arc of their own epic journeys.
At the same time, let the coat be thin enough to allow patients, colleagues, and friends to know your story, as well. Don’t create a shell around yourself. You are called to do difficult work. Don’t be afraid to experience and express emotion. Spend time with the underserved. Volunteer at the Saturday Clinic. Take extra time at the VA to hear a Veteran’s story. Run toward opportunities and challenges.
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I had thousands of “white coat moments” over my career. Even though I loved being in the operating room, my greatest joy occurred when patients allowed me into their family circles. I wasn’t perfect, but I was at my best when I slowed down, shut up, listened, and discerned what was really going on.
The German veteran who needed hearing aids taught me the value of listening. The woman with cancer who just liked to talk taught me the joy of accompanying those who suffer. I am grateful to them—and to the thousands of other patients—who extended me the privilege of being part of their lives while wearing my white coat.
My friends, take it from me, your career will be here and gone before you know it. If you are as fortunate as I have been, you will look back in about fifty years on a life that truly felt like a calling. In the meantime, I wish you the very best as you and your white coat commence your epic journeys together.
A few additional thoughts from a retired physician:
This lecture was delivered to the Medical College of Wisconsin incoming first year medical students on August 2, 2024. I am as separated in time from them as they are from the Class of 2076. Or as I was from the Class of 1932. As I put this together, I wondered what might they find useful or interesting? Would they say, "Okay, boomer," and pull out their phones?
We do not know each other's worlds. When I slipped on my first white coat, there were no MRI scanners, PET/CT machines, or surgical robots. Immunology was a complete mystery. Bioinformatics , molecular biology, and signalling were in their relative infancies. Surgical residencies were mostly pyramids. Work hour restrictions, HIPAA, ACA, DRGs, and EMRs did not exist. Smoking lounges were available in hospitals, patients could smoke in their rooms, and the cheapest cigarettes in town were sold in the VA Canteen. Medical education was, in the Flexner model, two years of basic sciences and two years of clinical rotations. HIV/AIDS had not yet been diagnosed in the US. The Tuskegee Study had ended only four years before and the Belmont Report had not been published. So much has changed.
During my years as an academic physician, Medicine, as a practice, became more post-modern, I think. Physicians became less guides and teachers and more technicians and purveyors of data. Medicine is now supposed to fix everything. Death is the enemy and must be fought to the end. And, unless something is documented, it didn't happen.
I am not worried about any lasting impact with this talk. I do not remember my own white coat ceremony at Rush in August 1976 other than I know it happened. I do not remember, for that matter, any of the speeches from any of my commencements or major moments. That offers me a challenge but also lets me know that what I do and say is not all that important in the grand scheme of things.
Still, it was great to spend a few minutes passing along some of the things I have learned over the past 48 years, especially in the world of Narrative Medicine. Shout out to Rita Charon and Arthur Frank, two of the many people who made me see the importance of stories in medicine.
Maybe one of the students I spoke to will give a talk in 48 years to the incoming Class of 2076. I wish I could hear that talk. I hope that the ability to listen to--and respond to--stories remains a theme even then.