In a moment both heady and fearsome, Judith Fleming took a few short steps across a stage at UC Irvine's College of Medicine one recent evening--and one giant leap into the world of science. She shook hands with a raft of deans and then was ritually cloaked in the jacket she someday will wear as a physician.
The uninitiated might assume it was an age-old ritual--but so-called white-coat ceremonies like this were unknown a decade ago. They have spread like a fever among the nation's medical schools in just the last five years: from 11 schools in 1995 to at least 125 of the nation's 145 medical and osteopathic schools today.
As classes began this fall at schools ranging from UC medical colleges in Irvine, Los Angeles and San Diego to private schools at the University of Chicago, Columbia and Stanford, more than 15,000 new medical students are being garbed and sworn to the ethics of their profession at ceremonies attended by hundreds of family, friends and faculty.
The new rite of passage, in which entering students are cloaked in the white jackets favored by physicians, comes complete with the age-old admonition of Hippocrates to, above all, do no harm--a step previously reserved for graduation. The ceremonies are designed to arm students for the complexities of 21st-century practice, focusing would-be physicians on caring and ethics from their first day of training.
Oaths Are Updated
As part of the event, students recite a version of that 2,500-year-old Greek oath, though most commonly the pledge is a modern update penned by the school's professors or recent graduates.
At UC Irvine, 93 students in the entering class recited a graduation oath written by UCI's class of 1977, pledging to "practice medicine for people rather than things."
The movement to focus on humanism in medicine comes as medical faculty, scholars and others worry that today's physicians will confront technological advances and economic pressures that will place evermore complex assaults on their professional values and interpersonal skills.
Among the technological developments that raise new ethical issues are techniques for allowing infertile couples to conceive--and, ironically, it was at UC Irvine that fertility clinic physicians were accused of violating patient rights in 1995. Among economic challenges is the movement toward managed care, which is forcing many doctors to balance the needs of patients against their own business concerns.
"There is no question that individuals practicing in the present environment are being ethically challenged far more than in the past," said Dr. Albert Manetta, senior associate dean for educational affairs at UC Irvine's College of Medicine.
"Our only mission when I began practice was to do the best you could for the patient without regard for any financial consequences. They gave you a ballpoint pen and a prescription pad and if you had ink, you could prescribe. Today, you have to align with institutional goals, and that can create conflicts."
The Journal of the American Medical Assn. in September reported that 90% of schools offer some kind of training in professionalism, and just over half have some means of evaluating students' professional behavior.
Nevertheless, the new tradition of white-coat ceremonies has its critics.
The UC Davis School of Medicine calls the goal laudable but the event not worth the hassle or cost.
"I am not sure what this adds," said Dr. Ernest Lewis, associate dean for medical education, adding that at Davis, the university prefers to teach ethics and humanism by example and spend the time picking students "with strong humanitarian skills and leanings."
"Reciting marriage vows does not ensure a perfect marriage or even a faithful one," Lewis said.
Started 10 Years Ago
The ritual got started at the University of Chicago in 1989, after a professor complained to Dean of Students Norma F. Wagoner that first-year students were "showing up in shorts and baseball caps" for sessions "where the patients are pouring their hearts out."
Wagoner decided the fix was to create a ceremonial program in which students were given physician coats. The school invited parents and told the students that "for any session where we have patients present, we expect you to look like professionals, wear the white coat and behave appropriately," she said.
The idea was batted around for a few years before Dr. Linda Lewis, dean at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor the first full-fledged white-coat ceremony.
It was held at Columbia in 1993, with the entering class reciting a modern version of the Hippocratic Oath. Formerly, that pledge had been taken only at graduation.
Gold, a professor at Columbia, said rearranging that oath's timing actually returns to the original concept of Hippocrates, who had students recite it at the outset of their apprenticeships.
"It was a condition of training," Gold said. "Instead, we had them taking an oath about the kind of doctor they would become at graduation. It was four years too late."
The Gold Foundation, which is dedicated to humanism in medicine, helps sponsor the coatings at more than 100 schools, providing grants and other assistance.
Nationwide, the ceremonies are treated like mini-graduations, complete with invitations, and often followed by a buffet reception with deans and faculty.
At UCI last month, nearly 500 people packed the Emerald Bay Room at the student center as each first-year student crossed the stage, was introduced by name, shook hands with professors and deans, then was assisted into a starched white coat.
Scores of doting parents rushed forward and snapped photographs.
UCLA had its fourth coat ceremony last month, with students reciting an oath written by senior faculty. Dr. Alan Robinson, vice provost of medical sciences and executive dean of the medical school, told the audience that the white coat is a symbol of "the mutual respect" that patient and physician must share.
He reminded the 177 students that despite managed care and advances in technology, they should "not forget the inner person. . . . Physicians should care as well as cure."
Longtime faculty members find the events stirring, especially so because it binds students to a creed that dates from ancient Greece.
"When I hear the oath I get chills," said Dr. Michael Prislin, professor of family medicine and UCI associate dean for student affairs. "No matter what happens in the advance of biotechnology, it is caring for other people that is timeless. There is a value to holding someone's hand. There is a reemergence of the themes of humanism."
Deans readily concede they can't prove the ritual works, but they tell stories of student enthusiasm.
Fleming of Los Angeles, the incoming UCI student, described the event as a comfort. After 13 years working as a veterinary nurse, she is humbled by the prospect of becoming a doctor, especially the "fear that I could do harm in this profession," she said.
"I want to be among people who are as gracious and compassionate and honest as possible," she said after the ceremony, adding: "My main concern is that my classmates would be irresponsible children who I couldn't trust with anything. I am very pleased to see the learning process includes this."
Several deans said an affirmation of humanism is needed now more than ever. For one thing, training is more rushed. Patient stays in hospitals are shorter, and students' time with them briefer.
"Today, a patient is admitted and goes home the next day," said Columbia's Lewis. "People in the hospital are so much sicker. The wonderful luxury of taking time with patients is no longer there."
In the few years the ritual has been performed, one moment has become emblematic. Through an oversight, administrators at Columbia in 1995 had failed to provide a coat for one student.
When Daphne Stewart, today a resident at UCLA, walked to the stage, the deans were at a loss. They shook her hand, shrugged their shoulders and sent Stewart back to her seat. Coatless.
In a moment that has become legend, Lewis spontaneously called Stewart back to the stage, took off her own coat and put it on Stewart.
The audience rose to applaud.
"I think it is so important to have these students be part of the profession and realize it is a giving, caring society," said Lewis, recalling the dual symbolism. "It seemed to be the right thing to do at the time."
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Oaths Old and New
Many medical schools have updated the 2,500-year-old Hippocratic Oath to reflect modern concerns. One written by UC Irvine's Class of 1977 and still in use at the school stresses the need for empathy and understanding toward patients.
The Oath of Hippocrates
"I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath . . . I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art . . . "
Oath for Doctors of Medicine (UC Irvine)
"I solemnly promise, as a physician, to practice my profession to the best of my ability. I will use my knowledge and skills to aid in the prevention, diagnosis, and treatment of medical diseases. I will try to help my patients to understand disease, treatment and prognosis. . . . I will endeavor to alleviate their fears, and recognize that occasionally the most meaningful treatment may be to listen with kindness and understanding. . . . I will live and practice medicine for people rather than for things. I desire that my empathy will never be subservient to skills and knowledge . . . "
Sources: City College of New York, UC Irvine