1/7/05

Medicine Mensch

This new series of articles in the Forward follows me through my medical training and, I hope, out the other side. I hope to talk about Jewish and medical topics which are sometimes broad, sometimes narrow, and often interrelated with each other. The first installment is here.

Here it is below, as well:

MEDICINE MENSCH: Today I Am a Short White Coat
By Zackary Sholem Berger
January 7, 2005
My first day as a medical underling.

Today I am a short, white coat.

Until last week, I was locked up in the ivory tower to finish my doctorate in epidemiology. But now it's finally time to learn how to be a medical student. I'm going on the wards, where I'll learn all manner of things: how to put in an I.V., how to build a rapport with annoying patients and how to avoid rampaging gurneys. To understand a hospital, you need to understand its hierarchy: when it's followed, when it's hallowed and when it's violated. I'll try to explain it all, but forgive me if we get lost. It's my first day.

The dilemma of the medical student with the short white coat — am I wearing it, or is it wearing me? — is as important to the person as it is to her wardrobe. On the first day of a new job, or in a new school, it's hard to know where to fit. All the more so in the topsy-turvy hospital hierarchy, where the most important person, the patient, has none of the economic or directive influence that powers the huge institution.

Starting from the very bottom, we first have the janitors, the cafeteria ladies, the orderlies, the "transporters" (gurney pushers) — anyone who makes sure that the huge hospital organism can fulfill its basic needs. Those of you who watch the television show "Scrubs" are familiar with the show's wisecracking, joke-playing janitor. He's completely in control, and jerks around J.D. (the medical resident who's the show's main character) to his heart's content. But if you've ever been inside a real hospital, you've never met a janitor like that. Sure, the janitors are friendly; sure, there's a modicum of genial give-and-take between upper (doctor) and lower (custodian). But at the same time, there's the uneasy reality that one is Over and one is Under, and never the twain shall meet. There is no magical moment of cross-understanding that one finds in Hasidic stories, when the rebbe realizes that the coachman greasing his wheels is just as spiritually attuned as he is. They are janitors, and that's that; no enlightenment is expected from them.

There are two kinds of uniforms in the hospital: medical and nonmedical. Janitors wear the second variety. Orderlies often wear scrubs of a laughably loud color, to point out just how removed they are from the medical hierarchy — the same reason that clowns wear the getup they do, to signal their freedom from normal rules.

Moving up a step, we find one of the most necessary groups of people in the hospital, aside from the administrators and money wranglers (who are sometimes known, unsurprisingly, as "the suits"). These are the nurses. It used to be the custom for them to wear white, but as uniforms everywhere become more and more casual, they've chosen the minimum amount of white to look a little bit like angels: white coats, white pants, perhaps a pair of white sneakers. The sneakers make them look like they're always on the way to or from Kol Nidre, which makes sense: If you'd like to build a community that's compassionate and practical, you could do worse than to convince the nurses to join you. It's smart to be nice to nurses in the same way that it's advisable to be on good terms with God.

One step above nurses is the medical student. That's me over here, not waving but drowning, trying to find in this rambling hospital the bathrooms, the library, the cafeteria and, most important, the stairs (the elevators are crowded and slow). While a long white coat looks dignified, flowing and somewhat old fashioned — a kind of medical kittel — a short white coat makes anyone look like a barber or an ice-cream scooper. Whether to counteract or exacerbate this effect, every medical student fills the pockets of her coat with a bewildering array of slips of paper, handbooks, equipment, tongue depressors, alcohol pads, pens, pencils, Palm Pilots and the odd bit of snack food. The rationale here is, I guess, "If I don't know anything, at least the pockets of my coat can be stuffed with facts."

On top, of course, is the physician himself. (I would write "herself," but it would be unrepresentative. The top rungs of the hierarchy are mostly male, even at this late date.) Their coats are long, with pockets that don't have to be filled with anything (the clinical experience and diagnostic certitude are all kept in the head at this stage, not on PDAs or in quick-reference books). Some doctors don't even wear coats — their rank is obvious.

The above hierarchy is just an approximation. There are enough exceptions and exceptions-to-the-exceptions to impress any devotee of the Talmud. For instance, at my medical school, at least until recently, surgeons wore scrubs and no one else did. Then, in a heroic mass movement, medical students decided that scrubs were comfy. They wanted to wear them, too! Now everyone can have his own pair. For some reason, though, only a surgeon wearing scrubs looks like a surgeon wearing scrubs. Anyone else looks like an escaped convict or someone whose last set of sweats is in the laundry.

The sick person wears no coat at all — aside from the robes that open in the back, like misappropriated evening gowns — and can feel as ashamed as Adam and Eve, the first naked couple. The rabbis of the Talmud said that the prototypical act of loving-kindness was God's providing loincloths to cover their nakedness. Even if I don't know anything about medicine yet, maybe I still can help patients feel better, no matter how short and overloaded my coat is.

Zackary Sholem Berger finished his doctorate in epidemiology from New York University this month, and will complete medical school in 2006. This is the first column in a series tracing his transformation into that mythical figure: The Jewish Doctor. Comments and questions encouraged at doctor@forward.com. No medical advice given!

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