White Coat Ceremony: Ritual and Mystery at the Heart of Medicine

Avery Elizabeth Hurt

“That is our brief – to stem the twin tides of magic and science, to insure a mixture of both wherever we can.”
From Interworld by Neil Gaiman and Michael Reaves

The audience is hushed, the mood reverent. This is a solemn moment for those who have gathered here. This is the day that first-year medical students will receive their white coats and take the oath of their future profession. If the event evokes the atmosphere of a religious ceremony, that is not entirely accidental, nor is it totally out of place. Those who are being honored here today are undergoing something very like a confirmation. These students are about to don the coat and take the oath that symbolically admits them to the priesthood of medicine.

In the modern world of overgrown steel-and-glass medical centers, noisy diagnostic machines, and pharmaceutical companies that vie with mortgage banks for the reputation for having the most reprehensible business practices, it can be difficult to think of medicine as a priesthood. But witnessing this ceremony it is abundantly clear that whatever a jaded public may think, the medical community still sees itself in those terms: its routines as rituals, its practitioners as modern-day shamans and wizards. The self-image may be mostly unconscious, but it is nonetheless deeply rooted. It is the shadow self of modern medicine.

Although the medical community indulges a sort of physics envy, lustily amassing data to use in its delivery of “evidence-based medicine,” arguing endlessly over research protocols, and picking away at the details of each other’s clinical trials, it is still deeply dependent on rituals and beliefs that owe more to magic than to science. That medicine should shy away from all connotations of magic and religion, yet in so many ways embrace them, says more about medicine’s self-image than its actual practice. Though physicians will cite studies and leave medical journals scattered about their offices, they rarely allow patients to see them look up diagnoses in their Harbison’s or use a computer program to calculate the dosage of a recommended medication. Many physicians are annoyed when patients bring in printouts of their own research or question the doctor’s advice. Patients are meant to accept as an article of faith whatever their doctors say. If you can’t trust your doctor, the unspoken message runs, perhaps you should find another. Physicians develop, support, and in large measure depend not only on the trust of their patients, but on an air of mystery and magic, despite all protestations to the contrary. This is more than some kind of medical power trip. Most complaints brought to the clinic are beyond the reach of medicine, often resisting diagnosis as firmly as they resist cure. A seminal study of military personnel and their families found that, of the most common complaints patients bring to their doctors, a physical cause can be found in fewer than 20 percent of the cases. For the diagnosable illnesses that most plague us – cancer, heart disease, Alzheimer’s – cures remain elusive. In all too many cases, mystery and magic and the faith of the patient are all the doctor really has in that iconic black bag.

The white coat ceremony, though ancient in aspect, is actually fewer than two decades old. The idea was conceived at the University of Chicago in 1989 as an attempt to impress beginning medical students with a sense of professionalism and a commitment to patient care. The deans who conceived the ceremony, and the ones who adopted it later, seemed to believe that modern medical students were slipping in this regard. The first actual ceremony was held at Columbia in 1993, and the new tradition swiftly spread to medical schools around the country; most of them now have some version of the ceremony. The hub of the ritual – besides the awarding of the coats themselves – is the recitation of the oath. While based on the ancient oath of Hippocrates, most modern medical schools use an updated version; some even substitute wording entirely of their own. At the University of Alabama at Birmingham School of Medicine, the students themselves write the oath as part of their orientation class. While the oath itself is subject to no small amount of controversy, and is not legally binding, the emotional import of taking an oath before being admitted to the training is quite powerful. It would seem that instilling professionalism, devotion to patient care, and the commitment necessary to endure as many as eight more years of training in what can often be a brutal, and is almost always a patriarchal, process is a task almost as daunting as diagnosing fibromyalgia or finding effective treatments for cancer. The white coat ceremony is the quintessence of the way medicine so often works, when it does work. “Deans readily concede they can’t prove the ritual works, but they tell stories of student enthusiasm,” explains an article in the Los Angeles Times.

Despite the fact that the white coat ceremony is a somewhat private affair, a passing of the symbols of the profession from one generation of healers to the next, it is also a very public moment. For the bestowing of the white coat is as much a concern of the public as of the profession. By allowing a person to call herself “physician,” allowing her to wear the coat and sling the stethoscope around her neck, society is bestowing both an honor and an expectation. And perhaps that is why the initiates seem to cross the stage with such trepidation, why the messages of the speakers seem to contain veiled threats along with words of praise and encouragement. For this is no small expectation: We require them to heal us of our ills. And that is a very tall order. An order that is perhaps even more difficult to fill in this age of clinical trials and evidence-based medicine than it was in the days of hand-holding, trust, eye contact – incantations that the older generation of physicians may not in fact be passing on at all, despite the stated aim of instilling a commitment to patient care.

When reflecting on the ceremony, it’s hard not to imagine that a day or two before the semi-public event there was a more private, quieter, and possibly spookier ceremony in a basement lab somewhere. Giving my imagination its head, I can see a stone room filled with boiling cauldrons and steaming test tubes; an ancient, bearded physician bestows the white coat on the shoulders of a kneeling initiate whilst mumbling fragments of that odd mix of Latin and Greek that passes for medical-speak. The young physician-to-be arises, looking around wide-eyed with wonder, subdued by the responsibility that has just been laid across his shoulders.

The ceremony and the aura that surrounds it, has nothing to do with science and everything to do with magic. Though modern physicians insist on thinking of themselves as scientists, the symbolism of the ceremony is anything but scientific. It is a charm, a ritual that is in many ways a last defense of humanism. These medical school deans are performing a magic rite in service of later rites. In these days of ambiguous evidence and ever more cynical patients, these physician-mentors are hoping to preserve something of the art that was for so long all they had with which to do their work, and one suspects may still be the best part of their craft.

If the stethoscope is the wizard’s wand, the white coat is his robe. It is a robe with neither stars nor dragons. No icons represent the source of power, just white to symbolize purity. And perhaps to suggest, to the jaded patient and the terrified neophyte alike, a blank page waiting for someone to write the spells, the magic formulas, the answers that will at last allow this priesthood to deliver on its promises, to make good on its side of the contract. They can’t prove their rituals work, but they have case studies of patient enthusiasm.