In a moment both heady and fearsome, Judith Fleming took a few short steps across a stage at UC Irvine's College of Medicine one recent evening--and one giant leap into the world of science. She shook hands with a raft of deans and then was ritually cloaked in the jacket she someday will wear as a physician.
The uninitiated might assume it was an age-old ritual--but so-called white-coat ceremonies like this were unknown a decade ago. They have spread like a fever among the nation's medical schools in just the last five years: from 11 schools in 1995 to at least 125 of the nation's 145 medical and osteopathic schools today.
As classes began this fall at schools ranging from UC medical colleges in Irvine, Los Angeles and San Diego to private schools at the University of Chicago, Columbia and Stanford, more than 15,000 new medical students are being garbed and sworn to the ethics of their profession at ceremonies attended by hundreds of family, friends and faculty.
The new rite of passage, in which entering students are cloaked in the white jackets favored by physicians, comes complete with the age-old admonition of Hippocrates to, above all, do no harm--a step previously reserved for graduation. The ceremonies are designed to arm students for the complexities of 21st-century practice, focusing would-be physicians on caring and ethics from their first day of training.
Oaths Are Updated
As part of the event, students recite a version of that 2,500-year-old Greek oath, though most commonly the pledge is a modern update penned by the school's professors or recent graduates.
At UC Irvine, 93 students in the entering class recited a graduation oath written by UCI's class of 1977, pledging to "practice medicine for people rather than things."
The movement to focus on humanism in medicine comes as medical faculty, scholars and others worry that today's physicians will confront technological advances and economic pressures that will place evermore complex assaults on their professional values and interpersonal skills.
Among the technological developments that raise new ethical issues are techniques for allowing infertile couples to conceive--and, ironically, it was at UC Irvine that fertility clinic physicians were accused of violating patient rights in 1995. Among economic challenges is the movement toward managed care, which is forcing many doctors to balance the needs of patients against their own business concerns.
"There is no question that individuals practicing in the present environment are being ethically challenged far more than in the past," said Dr. Albert Manetta, senior associate dean for educational affairs at UC Irvine's College of Medicine.
"Our only mission when I began practice was to do the best you could for the patient without regard for any financial consequences. They gave you a ballpoint pen and a prescription pad and if you had ink, you could prescribe. Today, you have to align with institutional goals, and that can create conflicts."
The Journal of the American Medical Assn. in September reported that 90% of schools offer some kind of training in professionalism, and just over half have some means of evaluating students' professional behavior.
Nevertheless, the new tradition of white-coat ceremonies has its critics.
The UC Davis School of Medicine calls the goal laudable but the event not worth the hassle or cost.
"I am not sure what this adds," said Dr. Ernest Lewis, associate dean for medical education, adding that at Davis, the university prefers to teach ethics and humanism by example and spend the time picking students "with strong humanitarian skills and leanings."
"Reciting marriage vows does not ensure a perfect marriage or even a faithful one," Lewis said.
Started 10 Years Ago
The ritual got started at the University of Chicago in 1989, after a professor complained to Dean of Students Norma F. Wagoner that first-year students were "showing up in shorts and baseball caps" for sessions "where the patients are pouring their hearts out."
Wagoner decided the fix was to create a ceremonial program in which students were given physician coats. The school invited parents and told the students that "for any session where we have patients present, we expect you to look like professionals, wear the white coat and behave appropriately," she said.
The idea was batted around for a few years before Dr. Linda Lewis, dean at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor the first full-fledged white-coat ceremony.
It was held at Columbia in 1993, with the entering class reciting a modern version of the Hippocratic Oath. Formerly, that pledge had been taken only at graduation.
Gold, a professor at Columbia, said rearranging that oath's timing actually returns to the original concept of Hippocrates, who had students recite it at the outset of their apprenticeships.