Marcellus Francis L. Ramirez
Apr 2018 DOI 10.35460/2546-1621.2017-0099
Last January 17, 2018, the newly accepted batch of residents and fellows of the University of Santo Tomas Hospital underwent the traditional White Coat Ceremony at the Benavides Cancer Institute Auditorium of the UST Hospital. Seventy-four incoming first year residents and thirty-eight new fellows from the different departments took to the stage to have their white coats worn to them by their respective mentors and training officers. The event’s inspirational speaker, Dr. John Hubert Pua of the Department of Orthopedics, spoke of his experiences as a resident during his training years. “Mistakes start to count after residency,” he claims. “In medical school, your mistakes result in lost examination points. In residency, the stakes and consequences rise. The manner that you deal with these mistakes mold you into clinicians. You must learn to evaluate your mistakes by confronting them and readjusting your approach.”
During training, whichever field one is in, there will be a particular patient that one will never forget, be it because of a “eureka” moment, a learning highlight, or a positive or negative experience during the patient’s care. JJ, as he is fondly called, narrated the story of one such patient. “This was an intoxicated 40-year-old male charity patient who mistakenly entered the UST Hospital Treatment Room (TR) before midnight in the Private Division because of a (profusely bleeding) hacking wound on his left hand.” It was deemed an emergency case as arterial injury was suspected. JJ recounted his experience in arranging for the surgery to be done despite lack of funds from the patient, and despite this, getting shouted at by the patient. After the successful intervention, he recalled that the patient thanked him profusely. “It actually felt good.”
Dr. Pua ended his speech with a special message that definitely reflects what wearing the white coat is all about. “Treat the patient and not just the illness. Treating the difficult patient is made easier by more than just the fact that they are our teachers. They allow us to prove our humanity and remind us why we do what we do.”
THE WHITE COAT CEREMONY: AN INITIATION RITE BEAMING WITH THOMASIAN PRIDE
In 1993, Dr. Arnold P. Gold instituted the first White Coat Ceremony at the Columbia University College of Physicians and Surgeons in New York (1). This ceremony was held with the background that medical students should be given well-defined guidelines regarding the expectations and responsibilities appropriate for the medical profession prior to their first day of education and training. Dr. Gold believed that a declaration of commitment, wherein students accept the obligations of the profession, should be taken at the beginning of medical school.
The history of the white coat dates back to the olden days. It has been a traditional symbol of the medical profession since the late 19th century. The donning of the white coat is a century-old tradition. Classic portraits and pictures depicting physicians even in the old days already shows them wearing this garb which serves as an identifying mark of a doctor. Having originated in scientific laboratories, it was adopted as the standard of dress by physicians as they sought to incorporate scientific principles in the practice of medicine.
Today, television, films, advertisements and paintings all frequently depict physicians in a white coat, most likely with a stethoscope slung around the neck. It is an easily recognized “uniform” of the profession that says, “I am a doctor”, and has been the most prominent and iconic symbol of the physician.
In an article published in the American Journal of Medicine, a study surveying patients showed that three quarters of patients favored physicians in professional attire donning white coats, whereas casual attire was only accepted by less than 5% of respondents. Physicians wearing professional attire with a white coat inspired confidence and trust among patients. The wearing of the white coat also showed a positive association with patients adhering to prescribed therapy (2).
Being a physical representation of healing, cleanliness and the idea of causing patients no harm, the white uniform also served as a professional barrier between the physician and the patient. Through this garment, the physician is cloaked with a powerful sense of authority. But more importantly, it also serves as a powerful reminder of their professional responsibilities to the patient and the community.
Today, the White Coat Ceremonies have been adopted throughout different institutions in the United States, serving as rites of passage and as an important milestone in the education of medical trainees. It traditionally occurs in the first year of medical school, setting the tone for the student’s commitment to professionalism and humanism.
This ritual is not exclusive to the medical field. The other health-related fields of audiology, chiropractic medicine, dentistry, occupational therapy, optometry, physical therapy, pharmacy, and veterinary medicine among others also hold this ritual that marks the student's transition from the study of preclinical to clinical health sciences. In some institutions, the ceremony marks the time that the students begin meeting patients in their respective hospitals, hence it is held before the first year begins. Over 100 medical schools in the USA now have a White Coat Ceremony. Regardless of whatever particular institution or field, the ceremony typically involves a formal "robing" or "cloaking" of students in white coats, the traditional uniform of the physicians which other health professions have adopted. The typical ceremony includes the presence of friends and colleagues, a welcome from the administration, an inspirational message from a role model, receipt of the white coat from a more senior physician, the swearing of the Hippocratic Oath, and a friendly reception.
Locally, among all the major training institutions, at least in the National Capital Region, the University of Santo Tomas Hospital is the first and currently the only training center that holds this particular ritual. A modified ceremony of a similar nature can be dated back to the time of Dr. Tito Torralba as medical director, but as far back as our review of the history of this ceremony in this institution, the formal ritual started in 2006, under Dr Caguioa as head of the Graduate Medical Education, and it has continued on with his successors.
Today, the UST Hospital continues to put priority to start each training year with such a ritual. The ceremony is held twice a year - one in January for the newly accepted residents and fellows, and another in June for the new postgraduate interns. Every ceremony serves to remind each attendee, whether new trainee, old trainee or consultant, of the dignity of the healthcare profession and of the responsibility in the conduct of this profession.
In 2014, the Department of Medical Education and Research of the UST Hospital, realizing that the original White Coat Ceremony was meant for medical students going into internship and patient care, decided to rename this important ceremony as the Thomasian D.O.C.T.O.R. ritual – the Declaration Of CommitmenT and Oath of professional Responsibility. Indeed, the ceremony served as the start of the trainee’s personal contract to the profession - a declaration of their commitment- to abide by the Thomasian principles, to do their best for their training, and to act ethically and professionally. The Hippocratic Oath that is traditionally recited will serve as a guiding compass in the care of their patients- their personal oath of responsibility.
In short, the ceremony is a declaration and an oath to be what a Thomasian Doctor should be.
- Arnold P. Gold Foundation Website. http://humanism-in-medicine.org/intros/gWcc-checklist.html.
- Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor's attire on the trust and confidence of patients. Am J Med. 2005;118:1279–1286.
Below is an excerpt from the Inspirational Message delivered by Dr. John Hubert C. Pua during the Thomasian D.O.C.T.O.R. – UST Hospital White Coat Ceremony for Residents and Fellows last January 18, 2018 at the UST Hospital:
Now before I begin, I’d like to ask all our incoming residents and fellows to give yourselves a thundering round of applause. Congratulations to all of you for making it this far. It is special for me to be giving this talk particularly to you first year residents because I remember handling you as students in UST med school before.
Yes, it is cliché to say that time flies. But it really does. Because now you are already here, more than halfway through in your chosen careers. Not as thin anymore, but not yet too fat. It is fair to say that residency gets the better of us, not just in age but in terms of our weight as well.
Because look what residency did to my weight. (During) my White Coat Ceremony back in 2007, Dr. Cabatu was the medical director then and Dr. Caguioa was the head of DMER, known back then as Graduate Medical Education Office or GME. Aside from learning a lot, I also gained 35 pounds in a span of 5 years of residency. You may have noticed that apart from my tuberculous weight, I had short hair then. It wasn’t for style or a fashion statement at that time. It was because I was a neurosurgery pre-resident here in UST two months back. And yes, I was not accepted into the neurosurgery training program. The reason? They chose the better applicant.
And so, that was when I learned my first and the most important lesson in residency. There is always someone better than you. And residency is the epitome of this. This is the basic concept of training.
To better illustrate this concept, it is better to use this Star Wars meme. As you ascend the ladder of medical training, your knowledge, clinical acumen, and surgical skills improve. With experience and impeccable mentors in one of the best, if not the best, training institution in the country, you become a master of the “force”. Although the terror that Darth Vader emanates as a consultant even if it is based on real people is, of course, entirely fictional and is purely coincidental.
Residency takes a long time and imparts permanent marks and dents to your life as a doctor. I remember my residency training not just inside the four walls of this hospital, but outside as well. By outside, I mean meetings, conferences, seminars and workshops that I attended in both locally and internationally.
What I am telling all of you is to take hold of all learning opportunities. I exhausted all possible avenues in expanding my training when I was a resident apart from the patient cases and department conferences I learned from. How did I do this? Research. Yes residents, it’s hard to admit but the research work that you dread or will dread will really bring you to places. The research paper requirements that DMER and your respective departments will ask from you may be additional workload but this can easily be remedied with foresight and proper planning.
Now burnout happens. It happens to everyone. The length of time and the amount of effort you will put during residency is no laughing matter. Doing the same thing every single day is redundant and will take its toll on you after quite some time into residency. This is where the social support from your co-residents come in. Take advantage of any down time and enjoy your annual vacation leaves to restart the spark and excitement that you still all have now at the start of your training.
In other words, break the monotony. A resident always has a great story about falling asleep at a ridiculous moment or in an absurd place. Mine is falling asleep in front of a consulting patient in the Out Patient Department while talking to that patient mid-sentence in broad daylight. Narcolepsy is a resident’s greatest strength because he is always on the tireless pursuit for rest and relaxation. So, enjoy your breaks and leaves to the fullest.
My first charity case when I was a first year resident was an open carpal tunnel release. I was the surgeon. As a novice, I remember making quite a large incision, feeling insecure and taking such a long time to finish the surgery. Much more during my first below knee amputation in which I think I had quite the intraoperative blood loss. As evolving trainees in your respective fields, this will be a constant feeling. The reason is simple and straightforward. You do not want to commit any mistakes since it is human life that you are dealing with. But I will tell you something. This is impossible. It is inevitable not to commit mistakes during residency. It is through our mistakes that we learn.
My mentor once told me that, “Mistakes start to count after residency.” In medical school, your mistakes result in lost examination points. In residency, the stakes and consequences rise. The manner that you deal with these mistakes mold you into clinicians. You must learn to evaluate your mistakes by confronting them and readjusting your approach.
During your stint as a resident, all of you will have a particular patient that you will never forget. This was an intoxicated 40-year-old male charity patient who mistakenly entered the Treatment Room before midnight in the Private Division last September 2010 because of a hacking wound on his left hand. It was bleeding profusely even after multiple attempts of packing with gauze and bandages. He did not have any money on him. Just a run-of-the-mill cellular phone that he was offering as collateral for his hospital expenses. I was a 4th year resident on duty at that time and deemed it an emergency case because I suspected arterial injury. We cannot transfer the patient anymore because he will surely die in transit from hypovolemic shock. After attending to all the fuss of arranging the logistics for the emergency surgery to be done stat, running back and forth to ask permission, to get signatures, I placed a tourniquet on the patient’s forearm for over an hour. While waiting to be brought to the operating room, he complained and shouted at me for making him wait and that he was in agonizing pain already. I shouted back at him and told him to shut up because I was doing everything already to quickly bring him up to the operating room. I think it sounded more ruthless in Tagalog, now that I recall. Needless to say, I did the surgery before sunrise, ligated his lacerated ulnar artery and repaired the transected tendons. Dr. Caguioa was the medical director already at that time and I spoke with him the next day and explained the patient’s predicament. Dr. Caguioa, of course, God bless him, allowed the patient to be discharged under the St. Cosmas and Damian indigency fund. Before discharge, the patient thanked me profusely. It actually felt good.
It felt good because I treated the patient and not just the illness. Treating the difficult patient is made easier by more than just the fact that they are our teachers. They allow us to prove our humanity and remind us why we do what we do. This patient actually became my car mechanic after discharge.
Your goal (is) to finish residency. Be prepared. Be ready. Because the next big ceremony you will be attending in this hospital after several years, when your white coats are not as white anymore, will be your graduation. A little older, a few pounds heavier but definitely wiser.
And so, I end with this. Success in any endeavor happens when you pay attention to the smallest details. Thank you very much and I will see you all again in your graduation.
Dr. Marcellus Francis L. Ramirez is the Chairman of the Department of Medical Education and Research and a Consultant Cardiologist of the UST Hospital, and a Faculty Staff of the Department of Medicine, UST Faculty of Medicine and Surgery.
Dr. John Hubert C. Pua is a Consultant and Training Officer of the Department of Orthopedics of UST Hospital, and a Faculty Staff of the UST Faculty of Medicine and Surgery.
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