Maureen A. Strafford, MD, was a champion of humanism in healthcare and a beloved friend and supporter of The Arnold P. Gold Foundation and its founders, Arnold and Sandra Gold. Dr. Strafford was the Arnold P. Gold Foundation Associate Professor of Anesthesiology and Pediatrics at Tufts University School of Medicine, and she spoke at several White Coat Ceremonies. She delivered this White Coat Ceremony address at Columbia University’s College of Physician and Surgeons on August 24, 2001. This version has been shortened slightly for the blog:
We are here today to perform a ritual called the White Coat Ceremony. Humans create and perform rituals because rituals are rooted in some ancient, sacred and wise understanding of the value of symbol and ceremony. Dr. Gold understood this when he began the White Coat Ceremony in 1993. The recitation of the Hippocratic Oath at medical school graduation is moving and meaningful, but Dr. Gold also knew, as only a compassionate and experienced physician could know, that the transformation begins in these very first days of your education as a physician. Dr. Gold was in fact reinstituting the ancient ritual that Hippocrates established when he required his students to recite the sacred Oath at the beginning, not the end, of their studies.
The White Coat … Just an item of clothing? Yet we endow it with great symbolism and power. We give uniforms and vestments and badges great meaning in so many other contexts. While I was gathering my thoughts in preparation for today, I remembered an item of clothing that seemed to also carry profound meaning and symbolism. When I was child (a million years ago, if you ask my children and yesterday if you ask my parents), I eagerly awaited the annual ritual of watching the “Wizard of Oz,” shown only once a year on TV on a special Sunday evening. This was eons before videos allowed endless rewinds and rewatching. It was a special, magical, important childhood memory. Who can forget the power of the Ruby Red Slippers! Don’t worry, you won’t be getting a pair today with your white coat.
But believe me there are some interesting similarities between Dorothy’s journey with her Ruby Red Slippers and your journey with your Snowy White Coat. For example, it was clear to Dorothy from the beginning that a lot of people wanted those Ruby Red Slippers — similar to all those people wanting an acceptance letter to medical school. And like Dorothy when she entered Oz, you may have noticed that you’re not in Kansas anymore. As in Oz, you will see things that you have never seen before, and you will see things that others are never permitted to see.
Like any good teacher (and good mother!) I want to save you a little time from the hard lessons ahead and help you understand why this white coat is so important and what you really need to fit into it well, so well that it becomes part of you like a second skin.
So back to Dorothy and the Ruby Red Slippers. After the Munchkins’ wonderful welcome, Dorothy nevertheless was panicked and really wanted to get back to Kansas. You, too, probably want to go to back to the euphoric time when you opened your letter of acceptance and you began (perhaps in front of the bathroom mirror in the morning) secretly addressing yourself as “Doctor.” You can only go forward, not backwards, and while there is no yellow-brick road, there is a well-defined road map that your teachers and mentors will guide you down.
Here’s what you need for the trip.
You need the same friends that Dorothy made on her journey: The Tin Man, The Cowardly Lion and the Scarecrow — not literally those characters but rather what they were seeking on their journey and what they earned at the end of the rainbow.
BRAINS! The Scarecrow was desperate for that diploma — that piece of paper that said he had a brain, was smart, creative and wise. In some ways, you too are desperate for that diploma. And yes, you do need that diploma to practice medicine legally. And yes, you do have the brains to do this work even though you’re worried that the Dean has just sent you a letter saying they made a mistake.
You have the BRAINS.
But here are a few pointers on how to best use that brain.
Study for yourself and for every patient that will come your way. Share your knowledge and knowledge will be shared with you. When you think you have learned it all, open the book and learn some more. Doing the hard work of learning will give you the “prepared mind” ready to make the critical connection, the correct diagnosis, the essential intervention.
Ask questions! You will find yourself sooner than you think in the position of having other people ask you questions, looking for wise and true answers. Take advantage of being the student. Are there any stupid questions? Of course, I am supposed to say no, but I’ll tell you one stupid question that I almost asked.
You will soon learn that doctors abbreviate every possible combination of phrases and diseases, to save time writing out those lengthy words, I’ve been told. CPR, ICU, OR, ER — you will soon find out that these are more than the names of TV shows. One of my friends covered the wall of his study with any new abbreviation he learned during his third-year clinical year. At the beginning of my third-year of medical school, my good friend Lisa and I were nervous, easily intimidated, students on our first rotation, surgery. The Chief Resident sent us to the ICU. “Go read Mr. Smith’s chart, examine him and be prepared to present his case to the team when we make afternoon rounds,” he bellowed. It felt a little like being told to go to Mars to get a cheese sandwich and come back. Intensive care units earn their name. Everyone there is very intense — intensely sick, intensely caring for the sick, and intensely not wanting to be asked stupid questions.
Lisa and I practically memorized Mr. Smith’s chart. He had undergone a major abdominal operation for a colon tumor. He was doing well. But there was one aspect of his disease and treatment that seemed to be a major part of his case. Everyone was talking about OOB. Every nurse reported in their note: “OOB today”. The Chief Resident explicitly stated in the order sheets OOB x3 today. Even the Attending Staff made it clear that Mr. Smith was “OOB”. OOB was clearly an essential aspect of the entire case.
We decided that both of us unfortunately had missed the crucial and unbelievably important OOB lecture in our preclinical years. We were cooked. The only thing we could do was go see Mr. Smith who wasn’t aware of our ignorance and hope for the best. I went over to see the pleasant gentleman sitting in a bedside chair, introduced myself and made some initial small talk by asking him how long he had been out of bed. Lisa immediately moved behind the patient’s chair out of his sight. Eyes popping out, she mouthed the words “O-O-B” — OUT OF BED!!!!
We were very glad we asked no one what OOB meant that day.
Learn from the nurses. Listen carefully to their wisdom earned by being at the bedside for many long hours. When I worked at the Shriners Burn Institute in Boston, we cared for children who were often burned beyond recognition. The scars left behind often created monstrous disfigurement. But at each child’s bedside, the nurse would place a photo of the child before his injury, wisely reminding us who was truly here in this bed, still perfect and a blessing, despite the bandages and scars.
Learn from your patients. That may seem quite obvious, but the subtlety of lessons that your patients offer will astound you. You must watch carefully. Mothers do know when their babies are sick. Patients do know when things are not right. Patients know when they sense death is near. When I was a cardiology fellow, children were routinely given painful injections before they went off, escorted by a stranger, alone to the operating room. One young mother was told that she should, at all costs, prevent her child from crying too much because his heart condition predisposed him to life-threatening “blue spells,” where blood to his lungs could be dangerously blocked by upset and crying. She followed the doctor’s orders faithfully.
On the day of surgery, however, she remembered her toddler crying on a stretcher, escorted by a stranger, as the elevator door closed and whisked him off to the OR. It was her last memory of him. He died on the operating table and when we shared this painful news with the mother, she chanted over and over that it was her fault. She had let him cry. She had let him cry. We could not convince her otherwise. Years later, when I began my work as a pediatric cardiac anesthesiologist, I vowed to somehow honor that mother’s grief. I was known as the one who never let them cry. My surgeon friends would complain to varying degrees about the delay to medicate a child or bring a parent into the OR for the beginning of anesthesia.
One day, well into my career, one of my colleagues showed me a clipping, a Letter to the Editor from the Sunday New York Times. “Remember this baby? Maureen. It’s you they’re talking about.” There was a two-paragraph letter, written in response to an article about doctors. It was a mother’s description of her baby’s heart surgery. She wrote,”On the morning of her operation, the doctor took the time to play with Victoria, to insure that our baby was happy being borne off by someone else who was, therefore, not entirely a stranger. That was our last memory of her, being carried, happy, down a hall, as she did not survive the surgery.” In some small way, I had finally honored the lesson offered me by my “crying, blue baby’s” mother so many years before. Learn from your patients in every way.
COURAGE! We all know the Cowardly Lion needed it. But you will need it even more. It is courageous to be here today. It is not an easy task to accept the responsibility of life-long learning, the mastery of complex skills and knowledge and the ultimate responsibility for another human beings welfare and life. It takes courage to give up the things of youth that this journey demands. Long hours, lost sleep, bone-weariness — none of it is glamorous. At times, it is even painful. At those moments, often in the middle of the night, your courage will be nurtured and sustained if you are wise enough to look to the courage of your patient. For me as a pediatrician, the courage of my small patients and their brave parents held me aloft in those moments of fear and near despair. When I was a resident in pediatrics, I cared for a 5-year-old little girl who was suffering from metastatic osteogenic sarcoma, a bone tumor that had already claimed her leg by amputation. Now we were assaulting her with powerful chemotherapy to stop the rampage of this destructive disease. One late night, after her mother had left, I was called to start a new IV so that no time would be lost with her poisons. It was torture to take her to the dreaded treatment room to stick and stab and find one last tiny vein. She cried when I entered her room. NO MORE HOLES! NO MORE HOLES! There’s nothing left of me inside NO MORE HOLES! She cried. I almost doubled over from the gut-wrenching emotion her words evoked for me. So I stopped and I held her as much to ease my pain as to ease hers. It seemed liked we held each other for a long time, and I could feel the softness come back into her small child body as she relaxed and calmed. I felt the same. She spoke first” “It’s OK, Doctor Maureen. I think I have one more hole left just for you.”
Courage. It will take indescribable courage to bring the news of death to a parent, a wife or husband, a family, a loved one. They will remember the subtle gestures of your announcement, the angle of your body as you sit next to them, how you met them in their pain and sorrow. It will take courage to know that there are no eloquent words to speak your message and it will take courage to sit in silence to honor the pain of grief with them. No medals will be given to the courageous people you will care for on your journey. Honor them instead with the respect and dignity they deserve.
A HEART. I’ve left this one for last. Not because the Tin Man was my favorite character (actually the Scarecrow was!) and not because I am a cardiologist, but because without a heart full of wisdom, the compassionate heart, you cannot truly know or accomplish the work and art of healing. Rachel Naomi Remen, who speaks eloquently about the need for compassion and service in medicine, summarizes well in her words this essential need for compassion:
“I don’t think that compassion can be taught. I think compassion is discovered, it is remembered. The great majority of students are deeply compassionate people. They come because they recognize the lineage of compassion and service at some deep level in themselves. And they want to be part of this. Compassion is not a behavior or action, it is a lived experience of profound connection from which all behaviors that we call compassionate arise. Compassion emerges from a sense of belonging, an experience that all suffering is like our suffering and all joy is like our joy. And when we experience this connection to all others, acting compassionately is simply the natural thing to do.”
Today, as we celebrate your accomplishments, let us celebrate also those who helped you discover compassion in your lives. One of the gifts of this speech was that it gave me an opportunity to publicly thank those most responsible for my personal discovery of compassion. Use this wonderful celebration today as a special time to thank those compassionate people in your life.
For me, my first teachers, my parents, remain models of compassion, two of the most compassionate people in the world for whom as Dr. Remen said “acting compassionately is simply the natural thing to do”. My sister, who is a remarkable nurse, and breathes compassion in her work everyday. My brother, who taught me the value of humor and compassion as a sweet elixir in people’s lives. I miss his presence in my life every day. My friend Mary Gordon, my dear story-teller friend, whose words on paper illuminated my life at so many important junctures and taught me the profound value of those who tell stories and those who listen to them as well. Finally, my husband, Alex MacDonald, who has always been compassionate and supportive about the demands of life with a physician and whose presence in my life has amplified me, made me a better person, Most passionately, our children, Nora and Emma. Becoming a parent brought the discovery of compassion into finer focus. Becoming a parent made me a better doctor, deepened my understanding and empathy towards my patients and their families.
Guard carefully all aspects of your life beyond these walls. If your life is balanced, observed thoughtfully and nurtured carefully, being a good physician will make you a better person, a better spouse, a better parent, a better daughter, son or friend.
Power, prestige, success dissolve during a moment of true compassion. It is the time when we are equal with our patients. It is a shared moment and profoundly important for the work you do. You will meet many compassionate people in these hallways. However, compassion, intelligence and courage must be blended like a finely woven tapestry to truly attain the goal of genuine healer.
When you meet and work with a genuine healer, you will know it. It is no accident that Dr. Gold created this meaningful ceremony, and it is no accident that through his work and the work of his wife, Dr. Sandra Gold and the Arnold P. Gold Foundation that this ceremony has gained such wide acceptance. Having had the honor of being a foot soldier under his direction while I was a pediatrics resident here at Babies Hospital, I know that his work, who he is as a physician and a person, embodies all that the White Coat Ceremony symbolizes and all you should strive for.
When I was a resident, Dr. Gold was always one of the most popular attendings at Babies Hospital. You hoped he would be your attending during your neurology rotation. He is smart, a skillful clinician with a compassionate heart reflected in the love and admiration of patients and families and clearly a wife and family that loves and adores him. He always made you feel smart, guided you to the right diagnosis and amazingly gave you the credit and made sure you were part of his team at the bedside.
Sharing a serious neurological diagnosis with parents is devastating. We so much define ourselves, our futures, our hopes by how our children will achieve and make the world better. The loss of such promise is a death of sorts. I remember Dr. Gold taking our team into the room of a beautiful 1-year-old girl. Her diagnosis was a death sentence. She had an aggressive and ultimately fatal brain tumor. Already, she had serious symptoms, serious losses. Her speech and motor functions were affected. Like Dorothy in the black-and-white world of Kansas, my fellow residents and I felt that things were clear, “black and white”, there was no place to go — it was all over for her and her family.
But Dr. Gold understood better than all of us the technicolor splendor of life, even life at the edge of death. He moved closer to our patient and her parents and spoke to them. I do not remember his words. I remember more that closeness. We residents seemed so distant from them. We were the acolytes watching a sacred, holy ritual. In those moments, we saw genuine healing. The examinations and the procedures had been done. The diagnosis deftly made. Now, we were privileged to be in that place. In the 14th century, Maimonides counseled his young physicians to remember: “May I see in all those who suffer only the fellow human being.” At the bedside that day, Dr. Gold eloquently spoke with his actions the prayer of Maimonides.
As I mentioned at the beginning of my talk, I was at an unusual crossroads, a time of challenge when I first had the privilege to speak at the White Coat Ceremony. The week I received my invitation, I had also received very disturbing news. My colleagues at the National Institute of Health had determined that I had developed a serious allergic reaction to certain anesthesia gases. I was asked to stop working in the operating room, to stop being an anesthesiologist — overnight, at a time in my career, when I had worked so hard and long to attain so many important goals. The OR was my home away from home. We leave our white coats on hooks outside the ORs but it a uniquely medical place — one of those places, like the anatomy lab of first year medical school, where not everyone is permitted to go.
I have not been back to the operating rooms and it appears that I never will return. I am redefining myself as a physician. So in many ways, I have also donned a new white coat a new way to see myself as a physician. What I do know is that nothing I learned on my journey has been wasted in my new pursuits. I have had a great deal upon which to build a new pathway.
So do you! Brains, Courage, Heart and your white coat — you have all you’ll ever need! Recognizing what you need is half the journey. Before I click my heels and recite that wonderful chant, “there’s no place like home,” let me remind you finally, that the true gift of Dorothy’s journey beyond the rainbow into Oz was that when she returned to Kansas, life was sweeter, love was more deeply felt, the simple, gentle gifts of life were more profoundly appreciated.
Tucked away in the pocket of your white coat, invisible really, is perhaps the greatest gift you will receive as a physician with your white coat today — the gift of appreciation for the miracle and mystery of life.
May you be a blessing and may you be blessed wherever you go with your white coat.