The views and opinions expressed in this collection are those of the authors and do not necessarily reflect the positions of the Association of American Medical Colleges.
Ali Khan will be a third-year medical student in fall of 2020. He has a passion for teaching so as to convey ideas to and learn from his students. Ali is interested in a career in which he is able to bridge basic science and community outreach to address health disparities.
White coat ceremonies in medical education celebrate the first time medical students put on their white coats. These ceremonies typically occur during the first week of the first year of medical school and are cherished by students, who invite their families and friends. At the front of big auditoriums, deans espouse the coats’ magics: wearing it, students are given more authority and their words are empowered so they must be conscientious of the advice they give to patients, a white coat lays a foundation of trust between patient and provider and doctors may hear from patients things they have never told anyone, and finally the white coat serves as an entry into the community of all physicians, an identity, and therefore acts as a shield of armor. It came as a surprise when my white coat did not protect against the stigma I face in the outside world due to my Pakistani-American identity. We as healthcare professionals and as people are taught to work beyond hurtful comments and actions imposed upon us by others, so we do. However, I see a growing need in medical education to address the wellness of medical students and physicians to prevent burnout that leads to poor care delivery and increased rates of physician suicide. Martin Luther King Jr. said, “Whatever affects one directly, affects all indirectly.” I immediately think about how we poorly prognosticate the effects of incremental mistreatment and act as bystanders to erosive processes that, for example, can disrupt the sacred interpersonal partnerships between doctors and patients, making all of us less safe.
As a medical student, I was able to see patients in the emergency room. One patient was immediately disturbed when I entered their room. I tried to determine what brought them in, but I left the room and told the doctor that the patient was not opening up to me and maybe it would be best if we went in to talk to them together. The doctor started by asking them, “Who is your primary care provider?” The patient, who was staring at the ground, looked up at me, pointed, and said, “Anyone who looks like him, I just call Achmad.” The patient went on to say, “I hope that doesn’t make you angry. I hope you won’t go and shoot me now.”
Here we are in the emergency room where cases are time-sensitive; people may come in with heart attacks or pulmonary embolisms. I felt guilty that my identity was a distraction. Later, the doctor I was working with took me aside and told me, “I’m sorry that happened. The patient decided to come to the emergency room but then decided to focus on you instead of themselves.” He continued, “They decided to delay their own care and the care of everyone else here today.” I understood. I still felt guilty, but most of all I felt that my white coat had failed me.
Over the next couple months, I had peers – people of color, women, LGBTQ students – share with me that they too were experiencing bias while wearing their white coats. They weren’t always lucky to find support in others like I did with the doctor I was working alongside. There is a growing diversity in the individuals who are adorned in white coats1 and a simultaneous growth in experiences like the ones I shared and those of my classmates – episodes, often repeated, of feeling guilty for being a distraction or out of place – as well as a discrepancy in which physicians are more likely to commit suicide2. Burnout is described as ‘emotional exhaustion’ and/or ‘depersonalization’ that can both decrease wellbeing of physicians and quality of care received by patients3. Looking at the macro- and micro-aggressions faced by some physicians, coming from patients, peers, and supervisors, it it is important to point out those early notions of unequal treatment that otherwise we would overlook or rationalize away.
Going further, burnout in medical professionals who face stigma in their white coats is confounded by a lack of support and in some cases mental health. I recently heard a statistic that shocked me: 41.8% of medicine interns experience depression4.
It is my mission to tell early medical students that we get to decide the next generation’s culture and atmosphere in the hospital; we get to decide how we care for patients, how we treat peers, and how we lead. First, we have to re-evaluate the past, including the legend of the white coat. We can recognize the white coat for what it is or is not, whether it has magic or not, and find magic somewhere else in medicine.
References
- Lett L, et al. Trends in racial/ethnic representation among US medical students. JAMA Netw Open. 2019; 2(9):e1910490. doi: 10.1001/jamanetworkopen.2019.10490.
- Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004; 161:2295–2302.
- Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. April 1981;2(2):99-113. doi: 10.1002/job.4030020205.
- Episode 129. Depression and suicide: occupational hazards of practicing medicine. ‘The Curbsiders Internal Medicine’ podcast.