Toga Alba: The Mysterious White Coat
Toga Alba: The Mysterious White Coat
The white coat is closely linked with the emergence of science and medicine throughout the ages. In ancient societies, the way healers dressed played an important part in their rituals, a practice described by Hippocrates who stated, “The physician must be clean in person, well dressed, and anointed with sweet-smelling unguents.” In medieval times, doctors donned brown or gray gowns just like lawyers did. A 15th-century Islamic medical textbook shows illustrations of psychiatric treatment methods drawn by Serafeddin Sabuncuoğlu, portraying the physician as neatly dressed and wearing a white turban on his head.
Across the globe in the Western world, physicians, as well as religious ministers, cloaked themselves in black and in paintings were portrayed in black garb until the late 19th century. In Thomas Eakins’ painting “The Gross Clinic” (1875), Dr Samuel Gross and his assistants are dressed in black formal attire, performing an operation on a young man. In Adalbert F. Seligmann’s masterpiece “Theodor Billroth Operating” (1899), Dr Billroth and his assistants were portrayed as wearing white coats, suggesting the idea that a new sense of cleanliness had permeated the operating room.
As a senior medical student searching for a residency specialty years ago in Ankara, Turkey, I found myself drawn to psychiatry for many reasons. I was impressed by psychiatry residents’ interest in the humanities, their intellect, and their liberal interactions with faculty members—and the fact that they did not wear the customary white coat. When I became a psychiatry resident, I adopted this practice and became perfectly comfortable wearing “street clothes.”
After I moved to the US, I worked as a research psychiatrist and, not surprisingly, none of my postgraduate mentors wore white coats either. As a faculty member at Vanderbilt University, my mentor attended administrative and research meetings in a business suit, but he changed into a white coat during his interactions with patients in the inpatient setting. Later on, when I repeated my psychiatry residency in the US, I still pondered the white coat, which continuously gained new meaning.
We physicians live in a new era, with integrated care in service for psychiatry patients. In the past, psychiatrists mostly invested themselves in de-medicalizing their discipline. However, that focus has been further refined, and psychiatry has been re-medicalized. Dr John Oldham eloquently described the principles of evidence-based, patient-centered integrated psychiatric care, which is as valid as ever—the integration of psychiatry in medicine, the right of quality treatment for all patients, the discernment of fragmented care as unacceptable, and the educational endeavors to enhance the future of psychiatry. All of a sudden, the iconic white coat emerged as a figurative, as well as a tangible, bridge between disciplines. It dawned on me that the art of creating patient-centered care requires effective collaboration, not only between psychiatrists, but between physicians in a bevy of other specialties as well.
The coat might well be a Rorschach test, eliciting positive and negative feelings toward psychiatrists. It is an emblem of professional authority for medical doctors, physician assistants, nurse practitioners, phlebotomists, social workers, and laboratory technicians. Spiritual care workers also wear white coats in many modern hospitals. The psychiatrist in the general medical hospital may find that the coat creates a calming, safe rapport with the patient. It facilitates his or her professional identity and serves as a gateway to acceptance among medical staff and patients. This is especially important for the consultation-liaison psychiatrist whose identity is not always clear to other physicians and nursing staff.
With the emergence of medicine, the white coat moved from laboratory to bedside, portraying the new power of modern medicine. Most patients view the white coat (“toga alba”) as a robe of compassion, a symbol of caring and hope they expect to receive from their physicians.
On the other hand, although psychologists I worked with have all agreed with the need for a professional dress code, in their world, the white coat has always been regarded as an unwelcoming mantle of authority, one that could impede communication in therapy sessions. In settings such as these, white coats might just induce white noise. I decided to test the white coat effect on medical ICU patients during my consultation-liaison rotation. The result should not come as a surprise. I have by far received a better response from patients and their families, as well as from the nursing staff, when I wear the white coat.
The mystery and the aura surrounding the white coat will never cease to fascinate me. Facing the daily challenges that our profession imposes on us, the coat, together with all that it symbolizes, serves as a gentle reminder to us of our purpose and our pride in our profession. The white coat symbolizes strength, courage, and the will to alleviate and heal mental suffering—which I believe to be in and of itself the most priceless reward imaginable.
Dr. Kose is a third-year research-track psychiatry Resident in the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston.