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Doctors first wore white coats in the late 19th century when science began to make significant inroads into medicine and physicians adopted the laboratory coat as their own.¹ Its initial purpose was to protect the patient and physician from cross-contamination, but, as the partnership between science and medicine² transformed hospitals from institutions for the dying to centres for curing the sick, the white coat became a potent symbol of the authority of science and the art of healing. Superimpose on this metamorphosis Western cultural connotations of whiteness — "life, purity, innocence, superhuman power, goodness — and it is easy to see how the white coat became the favored garment for physicians".^1,3

However, as the 20th century advanced, and sociologists turned their attention to medicine^4,5 and the dynamics of the patient-doctor relationship, the white coat was seen increasingly as a barrier to effective communication. In an attempt to dispel this perception, paediatricians, psychiatrists and doctors in private practice shed the white coat. Furthermore, the changes in society and healthcare that turned doctors into "healthcare providers" and patients into "clients, consumers or customers" also witnessed the extinction of the white-coated doctor. Today, doctors in our hospitals have become a hidden species, virtually indistinguishable from other hospital personnel or even patients' visitors.

But what do Australian patients want doctors to wear? In this issue of the Journal, Harnett explores this question.⁶ Among patients attending oncology clinics, a clear majority preferred junior doctors to wear white coats "for identification purposes" or because "it looked more professional". For senior doctors, the issue was not as clear-cut, but many of the patients still preferred these doctors to wear white coats.

These findings are not surprising. There is now substantive information that adult patients prefer doctors in clinics and hospitals to be traditionally, or at least smartly, dressed;^7-12 to wear a necktie;^7-9,11,12 to have short hair;^8,10,12 and to wear white coats with a name tag.^7,8,10-12

Does all this foreshadow a rebirth of doctors in white coats? Probably not. Most of the current information on patients' preferences for doctors' attire is derived from limited cross-sectional surveys. In the current era of evidence-based healthcare, any return of the white coat awaits the outcome of a randomised controlled trial to settle the question: to be or not to be in a white coat!

And yet, the practice of medicine involves more than its subservience to evidence or science. It also involves issues such as the meaning of service and feelings of professional pride. In this context, the white coat has become a symbol for the humane face of medicine and its professionalism in the newly discovered white coat ceremonies.¹³ To date a uniquely North American phenomenon, these ceremonies are performed each year for students entering US medical schools. The students (accompanied by friends and families) are welcomed into the profession by the assembled faculty of the medical school. After an address by an eminent member of the profession, each student is presented with, and helped into, his or her white coat by the dean and other faculty members. This robing ceremony is followed by a public proclamation by the students of their professional commitment akin to the Hippocratic Oath. Inaugurated in 1993 by the Arnold P Gold Foundation, the white coat ceremony had already been adopted by 93 US medical schools some five years later,¹⁴ suggesting a groundswell in the search for meaning in service to the community in medicine and in professionalism.

The Foundation has identified six components of the ceremony to "help create an environment which fosters a psychological contract for professionalism and empathy in medicine".¹³ These include

• The presence of friends and families "representing the support and value system closest to the student";

• The welcome by the dean and faculty of the school and its hospitals "representing the value system of the school and the new profession they are about to enter";

• An inspiring address by a physician role-model;

• The personal robing with the white coat through which senior doctors "demonstrate their belief in the student's ability to carry on the noble tradition of doctoring";

• A public proclamation by the students of the Hippocratic Oath or a similar declaration representing their "willingness to assume the obligations and responsibilities of the medical profession"; and

• A reception celebrating the students' new professional status "to reinforce an important and memorable moment".

The white coat ceremony is not without its critics who question its appropriateness and perceive a darker symbolism;³ nor are there comparable exercises in Australian medical schools. In these troubled times of uncertainty and confusion in medicine, might not the time be right to rediscover the white coat as a symbol of our purpose and our pride as a profession?

Martin B Van Der Weyden
Editor
Medical Journal of Australia

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©MJA 2001
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