Wednesday, December 2, 2015

The White Coats Are Coming! The White Coats Are Coming!

Let's say you were in a social setting, or even some business settings, and you introduced yourself to someone using your first name but that person's response was to introduce himself/herself using their last name and a honorific.  You might think they were oddly formal.  If, in those same settings, someone greeted you by your first name while introducing himself/herself using an honorific and his/her last name, well, you might think he/she was stuffy, if not a jerk.

Yet this happens all the time in health care settings.

Now, in the past, I've been critical of the use of the term "patients" to describe us laypeople in the health care system, arguing that it connotes a certain passive, secondary status about us.  Ashley Graham Kennedy, a philosophy professor at Florida Atlantic University, goes me one further: in a BMJ opinion piece, she asserts that "the title 'doctor' is an anachronism that disrespects patients."

How about that?

Professor Kennedy cites situations where doctors introduce themselves as doctors while not taking into account their patients' own professional titles.  How many of us have had a physician casually use our first name while expecting us to use their title?  If we happen to be sitting on an exam table or in a hospital bed wearing a gown that leaves us half exposed, the asymmetry is even more pronounced.

She notes that we don't need titles or even white coats -- more on that in a bit -- to figure out who our caregivers are or what their role in our care is.  More on point, she argues that the title is an explicit expectation that we are to treat them with respect, due to the training that the title signifies, whereas respect is something that deserves to be earned, such as by how we are treated.

It is the 21st century after all.  We know that not all physicians are equal, that not all medical education and training is the same, and that not even physicians know everything, even within their specialty.  If we're supposed to automatically respect all physicians, it better work both ways.

Personally, I don't mind calling a physician "doctor," although if he/she calls me by my first name (which I'd prefer) I'd expect that to be reciprocal.  What I wonder is what the title really means anyway.  There are a lot of "doctors" out there.  If someone introduces themselves as "Dr. X," you don't know if that means an M.D./D.O., or if it means DDS, DMD, DC, DPM, Pharm.D., DVM, OD, Au.D, Ph.D or ScD.  I'm sure that list isn't even complete, even within health care.  So as a means of automatically signifying respect for our physician, it's a pretty poor marker.

Some of the reactions to Professor Kennedy's argument are even more interesting.  While she believes that the deference the title expects is incompatible with patients being equal partners with their physicians, some respondents -- who usually seem to be physicians -- argued that the supposed partnership is not, in fact, equal, since physicians' training and experience makes them experts in a way patients can never equal, no matter how much Internet research they do.

I think those kind of responses kind of make Professor Kennedy's point.

The doctor/patient relationship is at its most asymmetrical when there is some acute event -- e.g., we have a heart attack, we need our appendix out, we need chemo.  But with more of our health care spending going to chronic conditions that, in many cases, are linked to lifestyle choices, the asymmetry is greatly reduced, and physicians should think twice about assuming they know more about maintaining our health, especially if they can't demonstrate that they "practice what they preach" when it comes to those kinds of healthy choices.

If the title "doctor" is a verbal indicator of expected respect, the white lab coat is a tangible one.  Almost all U.S. medical schools bestow one as part of their graduation ceremony (although this tradition is, surprisingly relatively new).  The fashion of physicians wearing them had to do with the (belated) acceptance by the medical establishment in the latter part of the 19th century that, yes, germs mattered; the coat was to suggest they kept their environment as sterile as in a lab.

Ironically, of course, the white coat itself may (or may not) be a carrier for germs, which has led the NHS to adopt a "bare-below-the-elbows" policy.

This is, apparently, a hot topic.  There are more issues than one might have imagined, including what physicians think patients want and -- my favorite -- how cartoons would portray physicians without a white coat.  Another opinion piece in BMJ bemoaned how the NHS "bare-below-the-elbows" policy has led to "scruffy doctors," urging them to "put your ties back on."

Not everyone agrees that the more casual attire leads patients to view doctors as scruffy and thus possibly lacking in hygiene.  (Dr.) Phillip Lederer wrote an excellent article on the controversy recently, reminding physicians that they'd still be a doctors even without the white coat.  He concluded: "There is no harm in avoiding white coats, but there could be danger in wearing one."

That would seem like the killer argument, but apparently it is not.

I mean, really, I can see wearing a white coat if the physician actually works in a lab, such as a pathologist, but it is hard to see it as much else other than a status symbol if they are actually seeing patients.  Health care is full of status symbols, including not just the white coats and automatically calling physicians "doctor" but also those nice parking spaces reserved for physicians that patients and their families often have to walk past, or, for that matter, major donors getting their names on health care buildings.

We shouldn't take any of them more seriously than if, say, all physicians started wearing monocles to further model those 19th century physicians.  The point is, it's not supposed to be about their status, but about our health.

Paul Revere may have never actually shouted "The British are coming!  The British are coming!" but he did help herald a revolution.  Maybe by rethinking some of the traditional status symbols in health care we can signal a revolution of our own, fighting for a health care system in which we are more responsible for our own health and are expected to be more equal partners with the people who help us with that.

Or we could try the monocles.


  1. First, it is the patient-physician relationship, recognizing that the patient is the more important part of the relationship as in patient-centered care. I also use the term physician to also sho respect for the physician as a medical doctor and not a Ph.D, DDS, DMD, etc.

    Yes, the patient-physician relationship extremely asymmetrical, even more so today. If not for the patient, the physician would NOT get paid. The patient also has the potential to upset the routine that the physician has come to enjoy by filing a malpractice lawsuit.

    Many times the true intentions of these law suits are not the reason listed in the lawsuit (such as a medical mistake), but reasons that are not considered malpractice such as rudeness, dignity/modesty violations, etc. Once a malpractice reason is found, a lawsuit is initiated.

    That is the reason that many seem frivolous, AND treating the patient with respect and dignity would have prevented most of these lawsuits even when there was a medical mistake.

    And then there are the satisfaction surveys…

    Many of the things that physicians lament may be caused by burdensome bureaucracy, the root cause is NOT the bureaucracy but something different. The root cause is a perception of a reduced value in healthcare services.

    Services that were once provided by physicians are routinely handled by lower level providers (nurses, PAs, NPs, techs, etc.). Much of what has been recommended has been based on ritual than science (CA screening).

    Then there is the disrespect and lack of dignity that patients are treated with; expectation and coercion to have others in the room during the most intimate parts of the patient-physician relationship (chaperones, students, scribes, film crews, etc.). Lack of gender choice in available providers is also another front to patient dignity.

    EHR, meaningful use, certifications, MOC, ACA, etc. all attempt to address the devaluation of healthcare by attempting to make sure that science is used and physicians are up to date on the latest scientific recommendations. Satisfaction surveys, cultural competency, lawsuits, etc. address patient modesty, dignity, and respect.

    Since physicians have refused to address these problems and have fallen back on the paternalism of the white coat, society has attempted to find a solution. That is how we got here…

  2. Maybe I'm old-fashioned (I do retire next week!), but I always introduce myself as 'I'm Dr Byatt' - but then until asked otherwise I call the patient 'Mr/s X'.
    This is the standard courtesy which I was brought up with and, as a geriatrician, applies even more so for my patients.
    I use the term 'doctor' because, in the UK at least, this has protected status both legally and socially - folk know what a medical doctor is, and what we do. With consultant nurses, pharmacists, etc arguably the word 'consultant' has now lost its specificity. The patient needs to know my name and my job. In secondary care most of my patients are acutely ill and not at their most relaxed or analytical; 'Hello Mrs X, I'm Dr Byatt - I'm your consultant while you're on this ward' has served me well over the past 35 years in conveying information, courtesy, reassurance and respect as efficiently as possible. The *vast* majority of my patients get it immediately!