Keeping the Flame Alive

This month, at medical schools across the country, first-year students will officially don the physician’s traditional white coat for the first time.

The white-coat ceremony is a powerful symbolic moment. It signifies that the students are moving beyond their identity as ordinary citizens and into their new identity as healers. The ceremony celebrates their idealism and their commitment to a life of caring for others. And, although they may not realize this, it constitutes a pledge to assume responsibility for their patients’ health and well-being–and the stresses that go with that commitment. As the students accept this responsibility, their lives will be forever changed.

In 1969, when I was a first-year medical student at Yale, there was no white-coat ceremony. Accepting my responsibility to my patients came in May of the following year, when I volunteered to be a medic for the demonstrators who were protesting war and racism on New Haven Green. We medics stood between the National Guard’s guns and the taunting demonstrators and urged both sides to remain calm. When the Guard fired tear gas, we retreated with the demonstrators and spent the night taking care of those affected.

Returning to our dorms at dawn, my friends and I agreed, “This is why we want to become doctors–to take care of those who need us.” It was a transformative experience. No longer were we just students or idealistic young people; we had a mission as healers. But we had no idea of the emotional toll that would be exacted by our choice.

My pediatrics internship was one of the happiest years of my life. I was finally helping people! Although I felt plenty of physical exhaustion, I avoided emotional exhaustion by engaging with my patients and their families as human beings. Some of my young patients did not survive: a premature baby who died in the NICU; a toddler in the ER, killed by his mother; a girl who died overnight from meningococcemia, and others. I dealt with my grief and stress by writing poems about them. The process continued during my training in child neurology. Some of the faculty supported my emerging humanism; others did not. As most residents know, connecting with patients often happens at 3:00 am, when no one is looking.

For the next twenty years, first in Texas and then in Boston, I provided mostly free care for poor, disadvantaged minority kids with disabilities. In 1986, as the chief of child neurology at a Boston hospital, I was working seventy-five hours a week. It was stressful, and I wasn’t making a lot of money, but I loved everything about it. I was living the mission and the identity that I’d accepted in medical school.

But things gradually changed. In a series of organizational changes, my authority as a division chief eroded, along with my nursing and administrative support. One day in 2000, after having spent hours seeing patients all alone in clinic, in the emergency department, in the hospital and in the ICU, I returned to my empty office feeling angry, abandoned and frustrated–on the verge of total burnout. I realized that I had to leave. With no idea of where I would go, I submitted my resignation.

Looking back, two things got me through this crisis: the humanism I had maintained since medical school, and the spiritual practices I had learned. Although I had no plans, I still had my relationships with my patients and their families–and I had friends. My friends invited me to join them at a nearby hospital and medical school, where I practice and teach to this day, and where many of my patients followed me. I have recovered and thrived in an environment that supports both my humanity and my humanism.

Since coming here, I’ve seen how much students and residents want and need their teachers and senior physicians to support them while the flame of their idealism still burns bright. The residents have twice honored me with their teaching award–mostly, I believe, because I’ve affirmed their idealism through my own efforts to practice humanism in medicine. Once, for instance, we were seeing a blind, quadriplegic hospital patient whose behavior had been quite disruptive. He calmed down and smiled when I came to him, held his hand and talked to him as I would to anyone else. Encounters like these can help the residents to see humanism in action, which is the best way to teach it.

I’m convinced that students who are putting on their white coats for the first time and residents who are working long hours in the hospital are as idealistic as ever, but times have changed. The bureaucratic demands of the electronic medical record can lead to demoralization: Am I working for the patient or for the company? Stress and emotional exhaustion are predictable in a medical career, and burnout may well be inevitable. For doctors facing these realities, the white-coat ceremony’s idealism may be hard to sustain.

As a medical educator, I wonder if part of the ceremony should be devoted to a truthful, sober discussion of the question, “Does your idealism have an expiration date? If so, how can you renew the prescription?”

My own experience is that humanism can be protective and therapeutic. Humanism saved my career and has given me unlimited refills on idealism, energy and inspiration. I believe that today’s students, given the right support and encouragement, can find a similar prescription.

On a practical level, given the stress and frustrations of practicing medicine nowadays, today’s students may need to approach their careers differently than I did. Some may choose to pursue their profession as in way akin to military service: Give it everything you’ve got for twenty years, then retire to a second, nonclinical career. Others may opt for a service model or a business model. There’s no one-size-fits-all answer.

Whatever choices these students make, I believe that the humanistic spirit expressed in the white-coat ceremony can be a common bond that unites them. We must encourage that spirit, so that it will continue to inspire every new generation of doctors in training.