The complexity of the white coat

18.01.2017
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I remembered staring at the computer screen with the radiologist hoping that by staring at the images, they would change in some way. It did not seem fair that a nice lady that I was evaluating in the emergency room would be consigned to such tragic images.

I was rotating through the emergency room during my second year of residency, and one of the patients had come in just for a cough, and part of her evaluation consisted of a CT scan of her chest. As one of my assigned patients, I was responsible for evaluating things from her lab reports to her imaging, and then informing her of any important findings. While I was talking to her, the radiologist called me to review the images with her. As we were scrolling through the images, instead of seeing healthy lung, we saw one nodule, then another, and then another one of many. By the time we finished reviewing the imaging, we realized that this was consistent with cancer, and that this would be a new diagnosis for her.

I was 27 years old at the time, and it did not seem right that someone as young as me would be conveying such sad news to a patient that was about as old as my mother. In medical school, I had this image of doctors as people who were able to find a solution to any medical problem, and that these solutions would be used to help prolong life, and in some instances save it. The white coats they wore seemed to be a sign of hope and possibility, and that is why my white coat felt a little heavier as I was walking back to this patient’s room to deliver this news that seemed to go against this spirit of hope and possibility. With each step, the coat felt like more of a burden, an unexpected feeling from a coat that seemed lighter at the beginning of my shift before this particular news.

When I arrived at her door, I asked her how she was doing. She said that she still had the cough but otherwise had no other complaints. Then, bracing myself for the potential reaction, I said that I wanted to talk to her about her imaging. To be honest, I don’t remember what I said next; all I remember are some of the questions I had in my mind during this conversation. How do I say this to her? Am I being too loud? Am I speaking too fast? Similar questions went through my mind and probably at some point, through some mangled way, I conveyed the news to her with as much sensitivity as I could muster while being a little flustered. As expected, she looked shocked and disappointed, but then what surprised me was that she then thanked me for this information. All she was asking about afterwards was what would the next steps be.

As I have gone through my medical training, I started to realize that the medical knowledge I was learning was a double-edged sword. With this information, in one respect, I could provide patients options in terms of treatable illness, but in another respect, I could tell patients that there was nothing further to do about their illness if it was terminal. It was the latter portion that made it difficult to see the white coat as a source of hope for people, but what was confusing to me at first was that because I was wearing this white coat, I was also obligated to convey information to patients related to a poor prognosis, depending on the amount of information that they wanted to hear.

In those moments, the coat felt like a burden at first, but then as I had more of these conversations, this piece of clothing started to change in front of my eyes in terms of its symbolism. It started to reflect the complexity of medicine, and that in this complexity, there would be moments of triumph and moments of sadness. The white coat just happened to be a part of all of those moments and in a way became a necessary piece of clothing in my mind when it came to medical conversations, particularly when it was regarding disappointing news. In that particular complexity, the white coat itself became complex.

Since that particular interaction, I have had more difficult conversation with patients with regards to prognosis.  In every single conversation, I was wearing a white coat with the thought that wearing it conveyed a sense of seriousness to my words, particularly when it came to a poor prognosis, and that this information had to be discussed with absolute honesty and compassion. What surprised me was that after I stated the situation, patients, and their families would then ask me about next steps, particularly when it came to patient comfort. I started to realize that somehow, with seeing me in the white coat, patients felt comfortable enough to ask me about what they should now expect with this news in terms of preparing for an ultimate progression of the illness to a terminal end. They showed me that even in their pain, they could believe that they could ultimately find comfort, and as such, the white coat became a source of hope and possibility to them again.

For me, with each similar interaction, the white coat becomes more complex, like an intricate puzzle that becomes more fascinating as new medical pieces are created through conversation.

Image copyright: Ali McCarley/flickr/CC BY

Article last time updated on 24.01.2017.

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