We've debated ditching the contaminated white coat many times. In these discussions, I've been struck by responses from colleagues who have clung to the white coat as a symbol of professionalism. I just didn't understand it. There are clearly other, safer ways to identify yourself as a physician, if you feel that is something you need to do. Of course, there are other ways to stay warm or have pockets (cool black vest anyone?) And it's not like the white coat ceremony dates back to Hippocrates or Osler. These modern ceremonies started in 1989 or 1993 depending on your definition.
So why did the modern white coat ceremony emerge and spread across the medical school landscape like...an infectious disease? I think the answer might be the decline in status of physicians in both healthcare and society. Within healthcare, doctors have been replaced by administrators as primary medical decision makers and in society our salaries pale in comparison to corporate leaders and other professions. Could the white coat (and white coat ceremony) be a vestige of the economic decline of physicians—a psychological defense mechanism?
I was pondering that question, when I came across a fascinating discussion by Malcolm Gladwell on a recent Ezra Klein Show Podcast. In the middle of the interview, around minute 30, they began discussing the decline of journalism. They wondered how members of a profession, who are losing their economic place, respond to this status free-fall. Gladwell was specifically interested in the psychological defense mechanisms that the professional groups adopt when in this free-fall. He says that the group becomes “very particular about who they want to let in or let out, they start to fetishize certain moral stances or positions or codes as a way of enforcing the in-group.” Gladwell then discusses a parallel example:
“It is this search for, when you lose one kind of status, one kind of point of differentiation, you have to replace it with something else. A very simple illustration of this is: why are pickup trucks so much larger than they were 25 years ago? Have you ever seen a standard Ford pickup truck of 1975 up against a Ford F-150 of today? The contemporary Ford pickup is literally twice the size … it dwarfs the old one. These are the same people buying those pickup trucks, doing the same jobs, but now their pickup truck is twice as big. And the answer is: in response to the falling economic status of white working class jobs, people have chosen to assert their status in another way. I may not make the kind of money or have the kind economic status that I had 25 years ago, so I'm now going to compensate by having a truck that is twice as big.”
It seems that the white coat (ceremony) could be a response to a loss of status of physicians in society. Perhaps this compensatory mechanism would be OK if unwashed, contaminated white coats didn't increase the risk of pathogen transmission in hospital settings. Similarly, large pickups would be OK if they weren't associated with poorer gas mileage and global climate change. Given that physicians have not lost as much power (yet) as journalists or the working class, it might be better to develop strategies to increase our role in medical decision making and maintain our economic status, rather than cling to a cold dirty white coat.
Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.