Size Matters

There’s that old adage of Lone Star narcissism and self-indulgence that everything in Texas is bigger. In the antebellum South, the diameter of a woman’s hoop skirt usually reflected wealth and status. Sumo wrestlers are the rock stars of Japan. The number of annular rings in a cross section of a giant redwood reveals its age. European royalty and judicial luminaries of the 18th century competed to don the most luxuriant and elaborately curled perukes. And in the adult film industry, well… let’s not go there.

In short, size (or whatever parameter of magnitude you desire) does matter.

[quick sidebar: customization matters too. In the American Civil War, common military conscripts were issued frumpy outerwear called sack coats, their similarities to the canvas potato bags of the day being unavoidable. Those stylish enlistees of means and middle rank, however, paid extra for a tailored version known as the shell jacket, that which men often are seen wearing in formal portraits of the day as the antebellum females swoon]

Combining those two observations brings me to an unmistakable ‘fact’ about the doctor’s white coat.

When I was a student, and later intern, we were issued the medical version of the sack coat. Formless, hip-length, off the rack, of coarse scratchy fabric, and with sleeves that were always ill-fitting, these atrocities made us look like the kids’ toy Weebles (who wobble but don’t fall down). Before long, they all looked dingy despite the number of washings. The young women in my class, and those few men regarded as clothes-horses, however, bought their own jackets of higher quality and had them tailored to fit and regularly drycleaned. All, though, were hip length. And by late intern year, many hold-outs had chucked their sack coats and opted for something more fitting albeit still utilitarian and of acceptable length.

As one progressed up the food chain, the quality of the coats and length improved (and, I would posit, the cleanliness). Upper level residents wore longer coats. Junior attendings a bit longer. And eminent attendings had coats of regal length – the perception magnified if that doctor was of short stature – with stylish pleating, belts, and fabric buttons in lieu of the cheap plastic ones on the government issued varieties.

As a psychiatrist, I only wore a white coat as an intern. After that point, at least at my medical center, psychiatrists tried to eschew the fearful “I’m the doctor and you’re not” phenom on the mental health wards and opt for the warmer and fuzzier Mr Rogers approach – khakis and sweaters. I know that’s a stereotype, but it’s true. And that’s how I’ve dressed for the past quarter century. Until recently.

I took a new inpatient position at a nearby medical center, and found that the psychiatric attendings there often, albeit not universally, opted for the classic white coat.

I know that much has been written about this tradition, but given all of the above, imagine my surprise when my intern arrived on the unit the very first day of the rotation… sporting a flowing and long bright white coat (with embroidered name in script, no less!) Her coat was far nicer than mine. For a moment, I couldn’t figure out who was this person until she introduced herself. She had been a physician at that point for less than five weeks.

Double my shock when I saw other allied disciplines – nursing, social work, pharmacy, technicians – donning the same attire!

I would have been shamed out of my residency program had I tried that back in the late 1980s.

Should it matter? No. Does it matter? I suspect in some ways, yes.

And while the egalitarians applaud, I doubt that the protocol at Mass General – where I am told that attendings wear short coats to symbolize that they are students for life – will catch on elsewhere anytime soon.

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