A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
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Chapter 4: Beantown

My wife and I proceeded through the interview phase for residency as we planned our choices for the upcoming Residency Match ("the Match" is a national process that connects med school graduates with post-doctoral training programs (known as residencies) in such fields as medicine, surgery, obstetrics, etc.). During the interviewing season, I climbed into my suit, and tried to make myself sound impressive. I had the grades and honor societies behind me, and as a result I wanted to go to a good program. I fell in love with Seattle when I was out there in October of 1983, but my wife, who was going to become a psychiatrist, found their psychiatry program antithetical to the type of psychiatry she was interested in. We had to go to a city acceptable to both of us, which had attractive programs in both internal medicine and psychiatry. Since we were both Yankees, we narrowed the choice to Chicago and Boston. Boston was our first choice, as it was smaller and more manageable than Chicago, in addition to having very good programs in both fields. We had a match list of over 50 permutations of our respective choices. In retrospect, it seemed a waste of time, as I got into my first Boston choice, and my wife her second.

The energy and enthusiasm generated by my internship (the first year of residency) was remarkable. It was a culmination of the educational process. I had learned a lot, and now it was time to apply it. An intern becomes the responsible person for all his/her patients. In reality, there was also a supervising resident and an attending (supervising) physician, but we, the interns, felt and were made to feel by others that we were the "man".

Internship was also draining due to its persistent demands. In our post-graduate training we experienced an even more profound indoctrination into the medical system. The medical training establishment allowed residents to buck the system to some extent, but social pressure toward greater conformity became important. It was not that one couldn't continue to function in an eclectic and possibly rebellious fashion, but that there were certain "rules" about how the system worked. While these were not formal rules, many of the unwritten ones were tacitly endorsed by the top of the pyramid, and were perceived to be validated by the public at large. This might be best understood by an example.

The hallowed white coat was clearly a revered symbol. This was reinforced at Boston University (BU) by the White Coat Ceremony. During a formal introduction ceremony, third year medical students entering their clinical clerkships would don a white coat for the first time. This was problematic in many senses. One problem related to a concept developed by the German philosopher Fuerbach, and used by Karl Marx in his protest of capitalism. That was the concept of alienation. Alienation refers to the distancing one has from an object or belief when a part of the internal human spirit is projected outside one's self. The concept of alienation may be better understood by considering the case of God. As Fuerbach would posit, by taking who we are as humans, perfecting it in an ideal form, and calling it God, we create a distance between ourselves, the actual human, and this perfected abstraction of our human selves. The perfected abstraction, God, when it is projected outside of ourselves into an external entity, comes to gain power it doesn't have before this externalization of the ideal human. As a consequence of this external projection of ourselves, we become alienated from the internal human qualities we have projected as God. These qualities are no longer seen as a part of us, but of this idealized, external agent. Physicians have done this with the white coat, giving it greater meaning and value than it has deserved, and in turn, a power the white coat could never have mustered on its own.

The white coat of a doctor had become an externalization of who the doctor really was inside the coat. The white coat had become a symbol of what took place in a person when training to be a doctor. This imagery was quite powerful. In fact, it was so strong that it even had a disorder named after it. "White coat hypertension" referred to people whose blood pressures were normal in their everyday lives, but would increase when they saw their doctor. I had joked with patients, that they couldn't have white coat hypertension with me, since I didn't wear one. Yet the reality was, I did have several patients who had manifested this phenomenon (which was easily documented by a 24 hour blood pressure monitor).

Thus, the white coat had become quite an important symbol of who we were as doctors. Over the years, many weight loss clinics have enhanced their image by dressing all their non-MD staff in white coats for their ads. In fact, the symbol was so important that at my hospital a couple of years ago, the Vice Chair of Clinical Affairs in the Department of Medicine wrote in a memo that all doctors needed to wear white coats in the hospital and clinic or wear their hospital IDs, so that people could tell who the doctors were. He even noted that the first choice of identification would be a white coat, and the hospital ID second.

As a result, I started brandishing my ID about my neck. Two years after this edict, many non-MDs in the hospital continued to wear white coats, including dietitians, nurse case managers, ward clerks, etc. So it seems we ultimately ended up with hospital IDs for distinguishing physicians from the rest of the crowd (if indeed such a distinction was necessary).

My second favorite MD symbol was the tie. Being male, I had been dealt the tie hand. I decided in my third year of med school that a tie wasn't for me. Recognizing the conformity issues present back then, I realized I couldn't always get away without one, so I would occasionally wear a tie. However, in due time, I concluded there weren't real barriers to not wearing a tie, only the ones I had fabricated in my own mind.

Now this wasn't totally true. When I saw patients, I had no problem convincing them that I was indeed a physician. By my manner, the questions I asked, the answers I gave, and the exams I did, patients had no problem discerning in their first encounter with me that, indeed, I was a physician. So, it didn't appear that the barrier to accepting a tieless physician was on the patients' side. The attitudinal barrier was really at the higher end of the medical pyramid. I had learned that those at the top really did have a concept of how an MD should appear. They would also in some cases, hold it against one if he or she didn't have a particular look. By "hold it against", I mean that every time a staff physician was picked for an assignment or task, the presence or lack of a tie and/or white coat became a factor that was considered in the decision. Race may not be allowed to be a consideration in such decisions, but white coats and ties were acceptable criteria to help guide decisions. After all, there was an image that needed to be conveyed.

In general, I had taken the view that I would just let my actions speak for me. This had worked well for the most part, and had allowed me to achieve at a high level. Yet I knew my style had been a barrier to advancement at times, and thus, something that I had to learn to accept. I suspect at times, not getting a position, or being pulled from one where I had literally been told I was doing a good job had more to do with my casual style than substance.

What was OK for a resident (in terms of dress and style) was not necessarily the case for attending physicians (those of us at a more established level who supervised the training of interns, residents and fellows). The assumption was that all trainees should outgrow such tendencies, and those that didn't, may have had a lesion (i.e. defect) somewhere which should be carefully monitored. So, in addition, to learning a lot of Medicine, and how to manage critically ill patients, I became imbued with the Medicine etiquette. Unfortunately, I came to the conclusion that I didn't like this etiquette. In fact, I had hoped that they (the medical establishment) would get over it, and stop holding it against me as opposed to my eventually conceding to the white coat, tie, etc.

The other point I should make about style was that it was also specialty dependent. For example, there were two large groups of MDs in the operating room (OR), the surgeons and the anesthesiologists. They two groups appeared identical in the OR. Both sets of doctors wore surgical "scrubs". Yet, before going into the OR, or while in the hospital at large, their appearances couldn't have been more different. The anesthesiologists came in dressed in relatively casual clothing, sometimes downright laid back. They may have worn ties, but definitely not a suit and only occasionally a sport coat.

On the other hand, surgeons, it seemed, could spend an hour getting ready in the morning, put on a three piece suit, come into the hospital, go directly to the OR, and take it all off only to put on scrubs. They would then re-dress after their OR cases, so they could look sharp once again. The white coat, when worn by a surgeon, would be perfectly buttoned up. Flowing tails from an unbuttoned white coat was definitely not acceptable (even amongst Surgical House Staff). If a surgeon didn't wear a white coat, a suit appeared to be mandatory, not optional.

If you think I am kidding, take a look at the apparel of the different MDs you come into contact with in the next 5 years. You will be able to guess their specialty 90% of the time based solely on their dress (this is my conjecture; I have no specific data supporting this statement).

As you can see, medical training was quite robust. It not only helped us to understand better the science on which Medicine was based, it also helped us to become familiar with the medical system. We learned how to process patients efficiently (and how to become indignant when this didn't happen). We learned how the class system in Medicine worked, and the need for conformity in this non-codified system. Finally, we were left with enough skill and ideas that we could go out into the real world, and try to fix all that we had identified as being wrong with the medical system.

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