Be well. Practice big medicine.

Vintage Big Med – B Schwartz | On the jingling of ‘change’ – May 2006

On the jingling of ‘change’ by Blair Schwartz 

[May 12 06]–I’m sitting now at the end of medical school and on the cusp of my residency. Truly an impressive time of transformation. As I sign contracts and insurance forms, it quickly becomes apparent to me the responsibilities that I am about to assume.

I no longer get to use the well-worn answer “That I’m Just a Medical Student” when answering patient’s questions. No, now I need to introduce myself as Doctor Schwartz and fight that urge to use those finger air quotes as I say doctor. I can sign my own orders for Tylenol™, perform procedures, fill out mountains of paperwork and work 30 hr shifts all on my own.

Yet, in spite of all these awe inspiring changes, right now, the one I am perhaps most looking forward to is being able to finally wear a full length white coat.You see, as if the endless scut, and running around doing others bidding wasn’t enough, we medical students were imposed one final subjugation: The Short Coat. It looks impressively like the standard white coat, with the final indignity of ending just below your butt. I’m sure there is some perfectly good historical reasoning for this decision, but one can’t help but ponder some ulterior and perhaps unsavory motives. All the same, it certainly does make for an interesting look as the ward team meanders about on its rounds.

The wizened attending in the lead, making small talk with the chief/senior resident amidst forced laughter all adorned in their long white coats. This group is followed by the junior residents, also adorned in the venerated long coat, out of earshot from the lead party whilst torn between straining to hear what was being discussed in front and carrying on their own banter about lack of sleep or poor progress of contractual negotiations. Lastly there are the medical students, easily discerned in the short coat, scurrying along at a frantic pace, hoping that the guffaws from up front are not in reference to their recent miscue and scouring the floors to pick up ANYTHING someone from in front may have inadvertently dropped.

I’ve witnessed this scene from within and as an innocent bystander and I can never help but to think of a medieval army. Led on by the horse mounted knights and their lord, followed by the well trained and venerable armored foot soldiers and at the rear are the efficient, methodical but defenseless and largely expendable archers.

The white coat is certainly a hot topic in the medical community, with physicians divided as to whether we should in fact still be wearing them. The theories surrounding the origin of this garb are diverse. Some claiming that by adopting the traditional garb of the “scientist”, physicians were attempting to portray the scientific nature of their craft and separate themselves from the numerous charlatans of the day.

Others take an elitist approach, that the donning of a pure white healer’s habit set a hierarchical boundary between the physician and patient as recommended by the medical ethos at the time. Still others are more practical and smock-like about it, why would you want to expose your clothing to the myriad of medical fluids that you encounter on a daily basis?

Whatever the origin, it certainly is a hot button issue with some branches, most notably psychiatry, leading the charge AWAY from the white coat and other disciplines leaving it to the individual physician to make the choice.

As a future resident, I am a member of the clan of those who do wear a white coat. Not because I think people need to be convinced of my scientific nature, nor my superiority or even to protect my clothing, because lord knows I don’t own anything worthy of protection. It is however, a functional decision. In spite of all the history and symbolism, for the average resident the white coat is a functional object and thus I present to you:

The Anatomy & Physiology of the White Coat.

Firstly, the white coat should be well fitted. Square on the shoulders with a loose flare towards the bottom. The latter is absolutely imperative as it permits the coat to billow out in an awe inspiring cape like manner as the physician rounds the corner into the hall en-route to an obviously important intervention. Then we have the accoutrements, often consisting of an ID card which serves to inform all who will take the time to read it that we do indeed work here. In addition to the ID card there are the pins, an attempt to express some sort of personality in the often bland medical machine. Some will go for the flashy waiter look and adorn every empty space with a button of some sorts. I choose to wear a small silver Maltese cross indicative of my membership in the Order of Saint John, but also because I love the confused looks from hospital staff as they try to figure out why a Jewish doctor is wearing a cross.

Then we have the pockets… oh the pockets!

The breast pocket is where we keep our pen light. It will fall out frequently & break, or be lost in the halls of the ward. It will never work on the rare occasion we actually need it, and yet, in spite of this we always buy another one. It is kept company by the pens, and much like a swordsmen has blades for every purpose, we too have a role for each pen. First there is the “throwaway”. Often a pen that we grabbed from somewhere, a cheap pen; perhaps picked up at a hotel or from some pharma rep. It is what we use for a quick signature, to jot down a note or two on rounds or when someone asks us to borrow a pen. Quick and dirty, it is akin to the dagger. Then we have the “writer”, the workhorse of the day. This is the pen we truly cherish, the one we purchased from the office supply store. We admire its grip, the manner in which it writes and its overall elegance. We use it to write orders, prescriptions, progress and admission notes. Like the old English Longsword it is our trusted companion and we would never go into battle without her. Some amongst us have the fortune of a “fancy pen”, perhaps a gift upon graduation or from a grateful patient. With names like Cross™ or Mont Blanc™ these are seldom seen out in the open, but like the ceremonial swords of the Queen’s Own, they do come out on special occasions.

Then we have the index cards. What once infused fear by its association with learning my multiplication tables has now morphed into the multi-purpose information recorder. Be it lab values, tests to check, patient information or the home phone number of that special someone they store them all. No coat pocket is complete without a stack of crisp white index cards and already used slightly grey ones strewn about.

Then there are the pocket guides. Varying colours and sizes covering a wide array of medical knowledge, from pharmacopea to anti-microbials and everything in between. These are the resident’s crutch, a tool to double check that he is not about to prescribe someone 10 times the lethal dose. Then there are the miscellaneous medical supplies: gloves, tape, gauze, tongue depressors, culture swabs, cathlons, vacutainers…etc, anything that a resident may need in the course of their day (and you thought paramedics had full pockets).

Then we have the large amounts of loose change. It would seem folly to include something that is a nuisance to many in a treatise on the white coat, but its importance can not be overemphasized. Some might say that AMEX is what nobody should leave home without, but remember the coffee machine at 03h00 doesn’t take credit.

I’m filled with both excitement and what I hope is a healthy apprehension about my upcoming transition. I know it won’t be an easy journey, but I have to admit that I just can’t wait to slip into that long coat and hit the wards. Just remember to listen for the jingle from the bottom of the coat pocket, and when you do hear it, smile quietly to yourself knowing that you are in good hands.

Be well and practice Big Medicine.

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