Inside Medicine: Doctor’s white coat may prevent communication

02/27/2014 12:00 AM

02/26/2014 10:38 AM

Perhaps the doctor’s white coat has it origin in protecting doctors from germs and other undesirable materials that their bodies might contact.

Today the white coat is both a literal and figurative barrier that separates us, doctor from patient.

In recent times, the only practical purpose served by the white coat has been the large pockets that had been useful to carry around medical “stuff” such as prescription pads, note cards and a stethoscope.

But much of this “stuff” is now dinosaur food – remnants of the past. We rarely write prescriptions on paper any longer and all our notes and lists are on our phones or tablets.

Today the white coat, like the neck tie, serves mainly to move germs from room to room rather than to promote hygiene. More important, it attempts to help prop the doctor up on a pedestal separating us from our patients and creating a paternalistic relationship.

The white coast is an important symbol – part of what we call the culture of medicine – it is a uniform akin to the robes worn by religious leaders or tribal chiefs.

The white coat, our unique language filled with medical jargon and acronyms, and our ceremonies such as grand rounds and morbidity and mortality conferences, are all part of what every new medical student must learn to become a member of the tribe of medicine.

It is time for things to change to balance the asymmetry of power in the exam room and allow for better care.

The white coat has contributed to a new malady we call “White Coat Silence.” In this condition patients are too intimidated by the power gap to ask doctors simple questions, perhaps out of fear of being perceived as ignorant or of taking too much of the important doctor’s time.

White coat silence can be a serious condition when the person leaves the hospital or clinic without a clear understanding of what is wrong and what ongoing treatments are necessary.

Many of us feel that there’s nothing better than when people ask questions of their doctor. It means there is discussion and listening. Questions enable the doctor and patient to engage in shared decisions based around what is best for the patient.

I am impressed with two websites ( ahrq.gov/questions and jointcommission.org), both of which help people organize their questions for their doctor and then allow them to print out a list to bring to their doctor.

Barriers will remain to balanced doctor-patient discussions. If doctors answer using technical medical terms, as they often do, the patients may not understand. A patient’s silence that follows such an explanation is often interpreted by the doctor as an understanding and agreement even when the patient didn’t have a clue what the doctor just said.

People need to be bold and insistent that they not leave the office without a complete understanding of their condition. It is also important to assess doctors’ experience doing what they are proposing – say a hip replacement. Too often in medicine, doctors often perceive such questions as, “How many of these surgeries have you done?” as threatening and a slam at their judgment.

We need new training for doctors, and they need ongoing practice and coaching. To improve communication doctors would greatly benefit from “talking tools” such as visual diagrams and risk calculators that could be used when talking with (not talking to) patients.

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