On Donning the White Coat: A Geriatrician's Perspective

Three personal stories reflect on a career in geriatric medicine. The stories are derived from a keynote address at the white coat ceremony at McGill University School of Medicine called “The Donning of the Healer's Habit” and a part of the physicianship curriculum.1Burton JR White Coat Ceremony Talk. Archived in the Osler Library, McGill University School of Medicine, 2021Google Scholar,2Boudreau JD Cassell EJ Fuks A Physicianship and the Rebirth of Medical Education. Oxford University Press, New York, NY2018Crossref Scopus (7) Google Scholar On call one night a week into my internship, I was responsible to visit the long-term care facility on our campus. There I was to assist the nurses with any acute problems. It was about 8 PM and before going to the long-term care facility, I stopped in the emergency department to admit a patient to the acute medical service. In the process of the admission, I spilled some Gram stain on my white coat. Rushed for time, I decided to go directly to the long-term care facility without getting a clean coat. I arrived on one of the units and introduced myself to the nurse who was about my age. She looked me over with a stern face and said, “Doctor, you're not going to see any of my patients. Not with that awful looking white coat.” She asked me to sit down and then told me about the medical director of the facility. Each day, he wore a newly cleaned and freshly pressed white coat with a fresh carnation in the lapel. He did this to honor patients. She then smiled and said, “you look exhausted, let me get you a cup of hot tea, a fresh white coat from our medical director's office and then we will see my patients together.” This first introduction to geriatrics was profound, lasting my entire career: A clean white coat shows respect for patients. Finding my career passion as a primary care geriatrician took time. In medical school at McGill University in the early 1960s, I became interested in a career in academic medicine and that interest grew in my postgraduate training at Johns Hopkins. Like my colleagues, I served in the military during the Viet Nam war. I went to Southeast Asia after only 2 years of my required 3 years of training. I was assigned to help a nephrologist because of the large number of soldiers who developed kidney injury. I did the equivalent of a 2-year clinical fellowship in kidney diseases. I became fully engaged in nephrology and liked the discipline greatly. After my tour of duty, I returned to Hopkins to do 2 more years of internal medicine and then a year of formal nephrology training in Boston. Then I joined the Hopkins faculty as a nephrologist. Although I loved my work, I felt something was missing. Why had I gone to medical school? It was to be on the front line of clinical medicine and serve as a generalist rather than a highly focused specialist. My mentor took time to understand the depth of my conviction. He listened carefully, even though he felt I was thriving in nephrology. I expected him to say that I should leave the academic environment and enter private practice. Instead, he said my idea had merit. He helped me work with the community to start a primary care practice near the hospital. It was fascinating. Clearly, this was my passion. I loved being on the front line with patients presenting with uncertain symptoms. I had to get to know them and guide them over time through complex illnesses. Each day was different and uniquely challenging. I loved general internal medicine and was excited to get to the office to practice each day. In a few years, this mentor asked me to consider moving the practice back to the hospital campus and focus on geriatrics. I pointed out that I had no training in geriatrics and knew nothing of the field. He smiled and said, “I know, but very few academic physicians do.” He pointed out the obvious: The number of seniors was rapidly increasing and their need for health care required new approaches. I became a geriatrician without any formal training. For me geriatrics was the perfect discipline. Older patients are complex, vulnerable, and challenging. The physician's role requires caution, judgment, and a careful understanding of the goals of care and guiding the patient over time and uncertainty. I loved it and every day was different. This clearly was why I had gone into medicine. This was my calling; this was my passion. A mentor who understands you, believes in you and has your best interest at heart is critical. A colleague asked me if I could see a close friend, an octogenarian who was failing and becoming bedridden. She had no children or close relatives. My colleague described her with admiration as, formerly, a vibrant woman, photographic artist, community leader, and avid gardener. She stopped going to her doctor despite her failing health from heart failure, spinal stenosis, frailty, arthritis, and hearing and visual losses. She would not take the medications as prescribed. Realizing the complexity of this situation, I thought it best to see her at home. I called her to ask if I could do a house call to start an evaluation. With that comment, the phone seemed to go dead when I heard faint crying. When I asked her if she was ok, there was more crying and then her faint hesitant voice said, “Thank you, you have given me hope that I do not have to face this alone.” Her live-in housekeeper described her as worn out. Her hospital bed was near a window in the living room. The curtains were drawn shut, and the housekeeper said they remained closed for more than a year. I asked to open the drapes to allow light for an examination. I was astounded to see a garden. She asked if I liked to garden. I explained that I had tried to grow dahlias for several years without success. Her face lit up, and she asked her housekeeper to take me to the garden. There I saw a patch of dinner plate dahlias. Over the months, together we worked to eliminate some medicines, begin ambulation, and get her to reengage in life. At subsequent house calls, she would take time to teach me the details of growing dahlias. She slowly reengaged in activities such as church, photography, and having visitors. After four satisfying years, she experienced a severe myocardial infarction and refractory heart failure. It was clear she was dying. She had no fear of death. During a house call, which we both knew was likely the last, she asked about the dying process. "How could I be certain death had come?" After struggling with this complex issue, she took my hand and, in a most gracious fashion, said “Thank you.” She said that her time had come, and she was ready to go. As we said goodbye, she smiled and said with deep feeling, “I am so pleased you grow dahlias every year.” I do, as do my children. Her memory and her teaching reblooms each summer with every dahlia blossom. At her funeral, my colleague pulled me aside and asked, with a warm inquiring smile, what medication had worked so successfully to help her over the last 4 years. We both shed tears as we discussed growing dahlias.3Burton JR On learning how to grow dahlias.Am J Med. 2018; 131: 329-330Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Wearing a clean white coat honors patients. Finding your passion in medicine and trusted mentors are essential. There is great joy and fulfillment in caring for patients, especially seniors with their age-related wisdom, insight, courage, and determination.