100 多年来，白大衣一直是医生的杰出象征。孩子对医生最早的记忆是穿白大衣的人。患者希望在医生办公室、医院和诊所接受身穿白色衣服的人的治疗。在几乎每所医学院，第一个象征性的行为是由医学博士 Arnold P. Gold 发起的“白大衣仪式”。这是准医生在开始医疗生涯时的仪式性“隐身”[1,2]。因此，您可能会惊讶地发现，在 19 世纪后期之前，医生穿的不是白色，而是黑色。
今天并不是所有的医生都穿白大衣——儿科医生和精神科医生都避免穿白大衣——也不是所有的专业协会都希望他们的医生这样做。丹麦和英国的患者不希望他们的医生穿白色衣服;瑞典、芬兰和挪威的患者希望这样做。研究表明，年轻患者更喜欢医生不穿白色衣服，而老年患者则相反[3]。
为什么医生对使用或避免穿白大衣的期望不同？白大衣最初是如何代表医生的？
坦率这个词来源于拉丁语 candidus，意思是白色。事實上，所有專業社會的基礎都是坦率或真理。“候选人”一词来自这样一个事实，即寻求公职的罗马人穿着白色长袍。几千年来，对正义的描绘一直是一个身穿白衣的人的雕像或绘画。当然，反之亦然，是用黑色描绘的邪恶或死亡。
直到 19 世纪末，医生们都穿着黑色的衣服，并被涂成黑色的衣服。黑色服装过去和现在都被认为是正式的（例如，今天的燕尾服）。因此，直到 1900 年左右，医生在与患者互动时都穿着黑色，因为医疗接触被认为是严肃而正式的事情。神职人员也身着黑色衣服，这表明他们在与教区居民相遇时所扮演的角色的庄严性质。深色服装的另一个或替代可能性可能是，直到 19 世纪后期，寻求医疗建议通常是最后的手段，而且往往是死亡的前兆。直到 1800 年代的最后三分之一，与医生的接触很少使患者受益。事实上，在那之前，几乎所有的“医学”都需要许多毫无价值的治疗方法和许多庸医[4]。
托马斯·伊金斯（Thomas Eakins）在1875年创作了可以说是美国最伟大的画作之一，名为“大诊所”（图1）。它描绘了费城杰斐逊医学院圆形剧场的一个场景，展示了塞缪尔·格罗斯博士和他的助手——都穿着黑色正装——对一名年轻人进行腿部手术。
大约在同一时间，防腐剂的想法在欧洲扎根。正是约瑟夫·李斯特（Joseph Lister）的贡献真正将医学从家庭疗法和庸医转移到了生物科学领域。可重复的结果首次帮助研究人员更好地了解如何防止细菌污染。
值得注意的是，Eakins 1889 年在宾夕法尼亚大学出版的手术室杰作《The Agnew Clinic》（图 2）中记录了这一进展。医学博士 D. Hayes Agnew 穿着白色工作服，助手也穿着白色，这表明一种新的清洁感弥漫在环境中。病人裹着白床单，护士戴着一顶白帽子。同样，马萨诸塞州总医院档案馆 1889 年的一张照片显示，外科医生穿着短袖白大衣，外面穿着便服。
在阿格纽画作之后不久，弗莱克斯纳报告（1910年）导致大量边缘医学教育机构关闭，并围绕实验室科学重组医学教育。再加上威廉·奥斯勒（William Osler）1892年的医学教科书和沃尔特·里德（Walter Reed）在巴拿马运河建设期间对蚊子传播疟疾的观察，清洁和防腐的价值被牢牢地固定为医学科学的核心。
在 19 世纪末和 20 世纪初，当医学成为我们现在所知道的真正科学事业时，医学的“白色”或“纯洁”反映在医生的服装上，有趣的是，护士的服装上[5]。在那之前，修女们的黑人习惯是护士，主要是在救济院。在19世纪之交，宗教护理团的黑人习惯变成了白人。事实上，直到今天，英国的护士都被称为修女，因为他们的宗教起源。我们的社会已经将这种白色的象征带到了婚姻祭坛上，新娘传统上穿着白色作为她们纯洁的象征。
在 20 世纪，白大衣继续作为医疗权威和尊重的象征，因为一次又一次的进步牢固地确立了医患关系作为一种有益的相遇。20世纪医学科学最伟大的发展可能是二战末期抗生素的出现——完成了李斯特勋爵成功克服细菌的梦想。肺炎、阑尾炎、感染的水泡或牙痛第一次不再被判处死刑。
身穿白大衣的医生确实是医学的象征，使黑色袋子或听诊器黯然失色[3]。但白大衣的形象也变得如此令人生畏，以至于儿科医生和精神科医生通常选择不穿它，以减轻患者的焦虑。术语“白大衣综合征”用于描述由于患者在穿白大衣看医生时的焦虑而导致的不具代表性的高血压记录。
许多患者现在将白大衣视为“同情的斗篷”[1]，是他们期望从医生那里得到的关怀和希望的象征。相反，在医学院开始学习的学生认为他们的教育和作为未来医生的角色渴望配得上长长的白大衣。医学院必须为学生提供成为医生的科学和临床工具。同样重要的是，白大衣象征着学生医学教育的另一个关键部分，是专业精神和关怀的标准，也是他们必须从患者那里获得信任的象征。正如戈尔德博士所设想的那样，白大衣仪式欢迎那些开始医疗生涯的人加入医生社区，为他们提供这种同情和荣誉的有力象征。它还为他们提供了一个标准，他们必须根据该标准来衡量他们对信任他们的患者的每一次医疗行为。
The Doctor's White Coat: An Historical Perspective
Mark S. Hochberg, MD
The white coat has served as the pre-eminent symbol of physicians for over 100 years. A child's earliest memory of a doctor is the person in the white coat. Patients expect to be treated in doctors' offices, hospitals and clinics by an individual wearing white. At virtually every medical school, the first symbolic act is the "White Coat Ceremony" originated by Arnold P. Gold, MD. This is the ceremonial "cloaking" of a doctor-to-be as she or he embarks on a medical career [1, 2]. So you may be surprised to learn that prior to the late 19th century doctors wore not white but black garb.
And not all doctors wear white coats today —pediatricians and psychiatrists eschew it—and not all professional societies expect their physicians to do so. Patients in Denmark and England do not expect their physicians to wear white; those in Sweden, Finland and Norway do. Studies show that younger patients prefer a doctor not to wear white, while older patients prefer the opposite [3].
Why do expectations about physician use or avoidance of a white coat differ? And how did the white coat come to represent physicians in the first place?
The word candor is derived from the Latin candidus which means white. In fact, the foundation of all professional societies is candor or truth. The term "candidate" comes from the fact that Romans seeking public office wore the white togas. The depiction of justice over the millennia has been a statue or painting of an individual clothed in white. The converse, of course, is evil or death depicted in black.
Physicians dressed themselves in black and were painted in black garb until the late 19th century. Black attire was, and is, considered formal (e.g., today's tuxedo). Consequently until about 1900, physicians wore black for their patient interactions since medical encounters were thought of as serious and formal matters. Clergymen also dressed in black, which indicated the solemn nature of their role in encounters with parishioners. An additional or alternative possibility for the dark garb might be that until the late 19th century seeking medical advice was usually a last resort and frequently a precursor to death. Until the last third of the 1800s, an encounter with a physician rarely benefited the patient. In fact, up to that point, virtually all of "medicine" entailed many worthless cures and much quackery [4].
Thomas Eakins created what is arguably one of America's greatest paintings in 1875 entitled "The Gross Clinic" (figure 1). It depicts a scene from Jefferson Medical College's amphitheater in Philadelphia showing Dr. Samuel Gross and his assistants—all dressed in black formal attire—performing a leg operation on a young man.
At about the same time, the idea of antisepsis was taking hold in Europe. It was Joseph Lister's contribution that truly moved medicine from home remedies and quackery to the realm of bioscience. For the first time, reproducible results helped researchers better understand how to prevent bacterial contamination.
Remarkably this progression was documented in Eakins' 1889 operating theater masterpiece entitled "The Agnew Clinic" (figure 2) from the University of Pennsylvania. D. Hayes Agnew, MD, can be seen in a white smock, with assistants also wearing white, suggesting that a new sense of cleanliness pervaded the environment. The patient is swathed in white sheets and the nurse has a white cap. Similarly, an 1889 photograph from the Massachusetts General Hospital archives shows surgeons in short-sleeved white coats over their street clothes.
Shortly after the Agnew painting, the Flexner report (1910) led to the closure of a large number of borderline medical educational institutions and the restructuring of medical education around laboratory science. Coupled with William Osler's 1892 textbook of medicine and Walter Reed's observation of the spread of malaria by mosquitoes during the construction of the Panama Canal, the value of cleanliness and antisepsis was firmly fixed as the core of medical science.
At the end of the 19th and the beginning of the 20th centuries, when medicine became the truly scientific enterprise we now know, the "whiteness" or "pureness" of medicine became reflected in the garb of physicians and, interestingly, nurses [5]. Up until that time nuns in their black habits functioned as nurses, largely in almshouses. At the turn of the 19th century the black habits of the religious nursing orders became white. In fact to this day nurses in England are called sisters, because of their religious origins. Our society has carried this symbol of whiteness to the marriage altar where brides traditionally wear white as a symbol of their purity.
In the 20th century, the white coat continued as the symbol of medical authority and respect as advance upon advance firmly established the patient-doctor relationship as a beneficial encounter. Probably the greatest development of medical science in the 20th century was the advent of antibiotics toward the end of World War II—the completion of Lord Lister's dream that bacteria could be successfully overcome. For the first time pneumonia, appendicitis, an infected blister or a toothache no longer condemned one to death.
A depiction of a physician in a white coat is indeed the symbol of medicine, eclipsing the black bag or the stethoscope [3]. But the image of the white coat has also become so intimidating that pediatricians and psychiatrists generally choose not to wear it in order to reduce anxiety on the part of their patients. The term "white coat syndrome" is used to describe unrepresentative high blood pressure recordings due to a patient's anxiety upon seeing a doctor in a white coat.
Many patients now view the white coat as a "cloak of compassion" [1] and a symbol of the caring and hope they expect to receive from their physicians. Conversely, students beginning their studies in medical school see their education and role as future physicians as aspiring to be worthy of the long white coat. Medical school must give students the scientific and clinical tools to become doctors. Just as importantly, the white coat symbolizes the other critical part of students' medical education, a standard of professionalism and caring and emblem of the trust they must earn from patients. The White Coat Ceremony, as envisioned by Dr. Gold, welcomes those embarking on their medical careers to the community of physicians by giving them this powerful symbol of compassion and honor. It also gives them a standard against which they must measure their every act of care to the patients who trust them.
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Health professions education/Medical education Health professions education/Learner roles and responsibilities Professionalism/Professional integrity Ethics/Practice
REFERENCES
Lewis LD. White Coat Ceremony keynote address. Speech presented at: Columbia University College of Physicians and Surgeons; August 26, 1994; New York, NY.
Enochs BE. The Gold standard. J Coll Phys Surg Columbia Univ. 1998;18:11.
Google Scholar
Anvik T. Doctors in a white coat—what do patients think and what do doctors do? Scand J Prim Health Care. 1990;8(2):91-94.
View Article PubMed Google Scholar
Shryock RH. The Development of Modern Medicine. New York, NY: Alfred A. Knopf, Inc.; 1947:248-272.
PubMed Google Scholar
Blumhagen DW. The doctor's white coat: the image of the physician in modern America. Ann Intern Med. 1979;91(1):111-116.
View Article PubMed Google Scholar
CITATION
Virtual Mentor. 2007;9(4):310-314.
DOI
10.1001/virtualmentor.2007.9.4.mhst1-0704.
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
阅读更多
卫生专业教育/医学教育 卫生专业教育/学习者角色和责任 专业精神/职业操守 道德/实践
Virtual Mentor. 2007;9(4):310-314. doi: 10.1001/virtualmentor.2007.9.4.mhst1-0704.
REFERENCES
Lewis LD. White Coat Ceremony keynote address. Speech presented at: Columbia University College of Physicians and Surgeons; August 26, 1994; New York, NY.
Enochs BE. The Gold standard. J Coll Phys Surg Columbia Univ. 1998;18:11.
Google Scholar
Anvik T. Doctors in a white coat—what do patients think and what do doctors do? Scand J Prim Health Care. 1990;8(2):91-94.
View Article PubMed Google Scholar
Shryock RH. The Development of Modern Medicine. New York, NY: Alfred A. Knopf, Inc.; 1947:248-272.
PubMed Google Scholar
Blumhagen DW. The doctor's white coat: the image of the physician in modern America. Ann Intern Med. 1979;91(1):111-116.
