White Coats - Part 1
From the moment they put on this garment, tomorrow's doctors face a gauntlet of germs, gut-checks and gross anataomy. A look inside the lives of three first-year medical students at Case Western Reserve University.
Enroll at the Case Western Reserve University School of Medicine and you will receive a short white coat. It is 65 percent polyester, 35 percent cotton and machine-washable only if you don’t care how it looks in four years. It will collect makeup, ink, dirt, blood and more germs than you can imagine. It will smell like pizza, sweat and embalming fluid. (But not all at the same time, let’s hope.) It will be your most challenging piece of laundry.
At the White Coat Ceremony in Severance Hall, a physician wearing a long white coat will help you put on your short white coat for the first time. Outside the medical profession, the few inches of fabric distinguishing your coat from his won’t matter much. The white coat is a sign that says, “Trust me, I’m a doctor.” It’s a ticket to other people’s secrets, a license to their bodies. It’s the uniform of the healer, and you will slip your arms into its sleeves and tug its fabric over your shoulders.
As you wait for your name to be called, you wonder how you’ll look in your new coat as you walk across one of the world’s great stages. The sleeves may be too long; the shoulders too broad. But there is a more important question:
How will you measure up when you put on the coat every day after this one?
The White Coat Ceremony
Aug. 14, 2005
Parents, spouses and siblings of the class of 2009 take their seats in Severance Hall. Not far away but completely out of sight, Marleny Franco is walking toward a smaller concert hall. She is wearing heels. Her journey from the Dominican Republic to Case Med has been made in flats, for the most part. Her heels lend a small but notable complication on this last stretch. But to look good in her white coat, she’s willing to risk a stumble down the steps.
Franco’s mother and sister are in the audience. Even her father is there. Her father, who has another family now. Her father, who believes in celebrating endings, not beginnings. Her father, who drove with her to Cleveland from Boston. She hasn’t spent so much time with her father in years.
Ebullient and 24, Franco sits, but she doesn’t want to. There are so many more people to meet. She turns in her seat, then around the other way, chatting, laughing, her smile warming the hall.
Mike Norton, wearing a dress shirt and tie and the laid-back confidence of a guy who likes to quote Dr. Cox from the NBC sitcom “Scrubs,” moves toward the concert hall slowly. Unlike some of his colleagues, who spent the previous evening drinking beer and spray-painting the Case logo on a table, he’s not tired or hung over. Two of his dreams are coming true at about the same time: Today he’s entering the practice of medicine, and in less than two months, he’s going to become a father.
While he’s awed by the intelligence of his colleagues, he’s not envious of their social lives. He’d heard med school was like returning to high school in that respect. Being Mormon, Norton has the church to fulfill his social needs. When he and his wife, Kate, moved from Utah to Cleveland a few weeks ago, they had friends instantly — and not just why-don’t-you-come-over-for-dinner-sometime friends. The Nortons’ new friends from The Church of Jesus Christ of Latter-day Saints helped them get out of the sketchy East Cleveland apartment they leased over the Internet and found them a nice duplex 10 minutes from school.
Things are falling into place for him, and he’s enjoying the simplicity of everything at the moment.
Millie Gentry arrives at the hall after Franco, Norton and most everyone else have been seated. Statuesque and thin with long dark hair and bangs that can’t decide how far in her face they’d like to droop, Gentry is tired from sleeping on the floor all week and preoccupied with the urge to shop for sheets. Her parents are here too. They came all the way from their small town in Arizona where they run a grocery store and where her high school classmates still don’t believe she’s in med school. It’s just not something many girls from Florence do. But then they don’t often pursue biology degrees at Smith College in Northampton, Mass., either. Or work as a model. Or move to Taiwan by themselves to teach English.
Gentry, 24, does things her own way. She parks her body in her seat, but her mind rambles.
“You’ve all passed the first test,” booms Dr. Amy Heneghan, associate dean for admissions, from the stage. “You’ve found your seats.”
There is some laughter, the barely audible kind. There is more chatter and fidgeting, the impatient kind. These are accomplished young adults ready to soar.
But, in some ways, going to medical school will be like returning to infancy. There is a new language to learn, new traditions to follow and new behaviors to model. This early in the process, women seem to facilitate the transition. After helping students find their seats, they process with them into Severance Hall where there are paternal figures too. On the stage are medical school dean Ralph Horwitz, M.D., and Eric Topol, M.D., provost of The Cleveland Clinic Lerner College of Medicine, a collaborative five-year M.D. program of Case and The Clinic in its second year. With Horwitz and Topol stand the society deans, the students’ advisers and confidants. They wear long white coats with red flowers in their lapels and face their still-coatless charges, for whom they are examples, teachers and mentors.
“Wow!” Horwitz exclaims from the podium.
Close to 5,000 applied to the school this year, and these 167 made it. They come from throughout the country. Fifteen grew up abroad. Most have research experience.
“Thank God we didn’t have to compete with them for admission,” Horwitz says.
For as long as she can remember, Franco has wanted to be a doctor. When she was 5 or 6, she spent late afternoons in the Santo Domingo hospital where her mother worked as a nurse. Instead of playing quietly in the waiting room, she wandered. And before her mother’s nurse friends could intercept her, she saw all sorts of forbidden things. The more blood and gore she saw, the more curious she became.
Her parents divorced when she was 9 and her mother moved her and her sister to Boston. Because her mother couldn’t speak English, she couldn’t be a nurse in their new country. So she became a janitor. When Franco’s father followed them to the city five years later, he too went from a professional job — working in a bank — to a blue-collar one. Even though Franco didn’t begin to learn English until she moved to the States, she excelled in school, especially in science and math, testing into the Boston Latin Academy in seventh grade.
She studied community health at Brown University and researched asthma for two years after college. She was accepted to seven medical schools, eventually narrowing her choice down to either the University of Pittsburgh or Case. Money was an important consideration, and Pitt gave her more grants. But Case impressed her during Second Look Weekend, when those accepted are invited back to spend time with students, faculty and alumni. She dined at the gorgeous home of an alumna and stayed out with other prospective students and Dean Horwitz until 2 a.m. (Franco saw Pitt’s dean for maybe 10 minutes.)
And it was a Case student who told her about the Jack Kent Cooke scholarship. Cooke awards a small number of graduate students as much as $50,000 for tuition, living expenses and other educational costs annually for up to six years.
You will get the scholarship, the student told her, and you will come to Case.
Although Franco wasn’t nearly so confident, she filled out the enormous application and waited.When she didn’t hear from Cooke for nearly three months, she assumed she didn’t get the scholarship. For her first year at Case, tuition would cost $37,944 and living expenses another $15,108. Even with her grants, Franco still had to sign a promissory loan for $41,116.
A few days later she found out she could cancel her loan. The Cooke scholarship was hers.
At the White Coat Ceremony, Franco walks across the stage to where her society dean, Dr. Charles Kent Smith, waits with her white coat, the clicking of her heels audible throughout the concert hall. She is thinking of “Harry Potter,” about the similarities of the heads of houses in their long robes and the deans in their long coats, the students looking to them for guidance.
Becoming a doctor is a colossal undertaking. There’s so much to learn and so little time to learn it. Are brains, hard work and dedication enough? Or will they need a little magic too?
“Shazam!” Horwitz exclaims, as the students rise and face their families. “How did this happen?”
In an instant, they have gone from a mish-mash of dresses and suit jackets to an army of immaculate white coats.
Three Days Earlier
E301, the third-floor lecture hall, is noisy and too warm. The students wear khakis, jeans, ball caps, spaghetti straps and sit wrist-to-wrist, knee-to-knee, mostly behind faculty and administrators in white coats in the front rows. Horwitz stands before them, holding his glasses with frames that look as if they’ve been speckled with brightly colored paint.
He walks around, quoting William Butler Yeats (“Education is not the filling of a pail, but the lighting of a fire”), the enthusiasm sparking off him. He moves back toward the podium only occasionally, reluctantly, not unlike a pinball when gravity first overtakes it, coaxing it back toward the paddles.
In what seems like a competitive way to start off a noncompetitive, pass-fail year, he calls the students to stand and recite their names and undergraduate institutions. Years of study in an incredibly rigorous professional orientation await these students, and Horwitz kicks it off with a simple round of applause from the faculty, building up the students’ confidence before the work can tear it down.
Mike Norton sits in the front row. At 4, he was fascinated by stethoscopes. By the time he was 8, he owned a microscope, a telescope and a chemistry set. At 11, he earned a Boy Scout merit badge in atomic energy.
Academically, everything Norton has done — including the Advanced Placement science courses he took in high school and the microbiology major he completed in college — he’s done to get into medical school. He’s here. Now what?
Around the time Cleveland Medical College (Case Med’s predecessor) opened in 1843, American medical education was the worst in the industrialized world. During the Civil War, doctors were still bleeding and blistering patients, even though French schools had proved such “remedies” ineffective long before. Kenneth Ludmerer’s book “Time to Heal” is rich with such anecdotes and plenty of scary facts about early medical education in America. To really learn medicine in the late 19th century, you had to travel to Europe.
But as the decades wore on, the Cleveland school improved its product faster than most. In 1910, Abraham Flexner issued a ground-breaking report on medical education, criticizing schools for their low standards and urging reform. The report fueled a revolution in medical education, which resulted in medical schools moving to universities, faculty working on original research and students being taught both in labs and clinical settings. In a letter to Western Reserve University president Charles F. Thwing, Flexner complimented its medical school, saying the quality of its education was surpassed only by Johns Hopkins.
Western Reserve drew attention again in 1952, when it pioneered a new curriculum — one that addressed some big problems with traditional medical education: students feeling overwhelmed by the crush of information, memorization being stressed over analytical skills and the separation of basic (the first two years) and clinical sciences (the last two).
At Western Reserve, Dean Joseph T. Wearn started students doing clinical work during the first year, treated students as colleagues and integrated basic and clinical sciences. Instead of teaching individual subjects — pathology, for instance, covered the pathology of the whole body in one course — Western Reserve faculty taught organ systems. Students learned everything about the heart when they studied the cardiovascular system, including its biology, histology and pharmacology. Other medical schools then consulted the Western Reserve model in revising their own curricula.
In 1967, Western Reserve University merged with the Case Institute of Technology to become Case Western Reserve University, whose medical school’s reputation remains strong today. It’s ranked No. 22 (out of 144 accredited medical schools) by U.S. News and World Report. Eleven Nobel laureates and two U.S. surgeon generals have connections to it.
Horwitz only skims the history and the accolades, however. His main topic is conduct. The term “civic professionalism” makes its official debut. There is no drum roll, no curtain rise, just the excitement in his voice, which hints to its importance with the subtlety of a trumpet blast.
Norton wonders, What kind of fluff lecture is this? He doesn’t realize that under Horwitz’s leadership, Case is poised, once again, to launch a bold new curriculum, one with civic professionalism at its core. While the needs of the students drove the 1952 curriculum change, the needs of the community are driving the one in 2006. By integrating the studies of medicine and public health, future Case Med graduates will concern themselves with the health of the community, considering the social and behavioral contexts of illness.
Through the curriculum shift at Case, Horwitz wants to redesign the physicians’ social contract: Society allows doctors to manage their own profession — including determining how they treat patients and conduct medical research and training — and in return they must serve not just their own patients but the public as a whole first and foremost, putting its needs ahead of their own.
(later that day)
Marleny Franco stands at a podium, typing on a laptop computer in front of a large screen that displays the list of values from which the class’s “Oath of Professionalism” ought to spring.
She is there after all but eight of her colleagues have gone home because she feels strongly about alleviating health-care disparities. In the Dominican projects where she grew up, she was la hija que sabe Ingles (the daughter who knows English), the one who filled out medical forms for her mom’s friends and Spanish-speaking strangers at the local health clinic.
Years later, while doing asthma research in Latino communities, she was shocked by how little the parents knew about their children’s disease. They told her things they’d never tell a research assistant who didn’t speak their language.
“You know what it’s like in the DR,” one parent said before mentioning the home remedy of “lizard in boiled milk” for asthma. Franco had never heard of such a thing. But by explaining things in their language, she made herself worthy of their trust.
Franco wants to work with people like her research subjects, the people she can help most.
She figures she can start by getting equal health care into the oath.
At 3:15 p.m., the students have about 45 minutes to finish.
Number of lines so far: 0.
“This is the hard part,” society dean Elizabeth McKinley, M.D., says empathetically. “How do you get it down to a couple of lines? It’s hard.”
Around 3:40, they ask for an extension.
“You’ve got to get this done,” McKinley says, less empathetically.
Finally, a breakthrough: two good lines.
“Today we begin a lifetime of responsibilities to our patients, our society, our colleagues and ourselves. We will strive toward honesty, integrity, open-mindedness and compassion.”
Franco worries she’ll have to argue to get her conviction in the oath. Just because all the students want to be doctors doesn’t mean all believe health care should be available to everyone equally. Earlier in the day, at least one group debated the merits of universal health care.
They don’t make the deadline, but they finish. With no resistance at all, Franco lands her views in the second-to-last point: “We will provide impartial and compassionate care without discrimination and judgment.”
At last, she can go home.
Fundamentals of Medical Decision Making
In E301, Millie Gentry is wearing a “Pam Anderson” name tag and a halter top stuffed with toilet paper. Along with “Martha Stewart,” “Naomi Judd” and, of course, “Tommy Lee,” she is relaying Hepatitis C information in “Hollywood Squares” fashion.
I feel really stupid right now, runs through her head like a refrain. No one else from her group is really in costume.
For Gentry, this is worse than when she stumbled off the stage at the White Coat Ceremony (Franco feared it; Gentry actually did it).
No one’s laughing at this embarrassment.
In Fundamentals of Medical Decision Making, otherwise known as the cakewalk before Biochemistry, laughter is how the med students evaluate each other’s public-awareness skits. And so far, her skit is last on the chuckle meter.
It’s just not as silly as Willy Wonka’s Happy Fun Time Alzheimer’s Clinic or as clever as the “Austin Powers”-inspired ode to prostate-cancer screening — starring Norton and Franco as a married couple. Even a somewhat disturbing skit on lead testing drew laughs with a diaper-clad med student and songs that would make Barney proud.
Gentry feels as if she’s in school with a bunch of “gunners,” students who want to ace everything, even in this pass-fail year.
She is at the other end of the spectrum, haunted by the memory of three garbage bags overflowing with notes, papers and exams from her undergraduate years.
While other people were making friends, meeting significant others, joining clubs, learning other languages and just living, Gentry was studying hard, filling up those bags.
Although she loved Smith and found the quality of teaching at the small women’s college excellent, she didn’t want another four years to pass with her head buried in books. So she has embarked on what may be an impossible pursuit — to become a medical student with a life.
She had hoped the “Pam Anderson” on her small-chested frame would get a few laughs. It didn’t.
Norton, sitting next to me in the lecture hall, seems more proud of his group’s prostate-screening infomercial. He doesn’t participate in the skit that follows, which includes Nurse Alotta (after Alotta Fagina, one of Austin Powers’ paramours) snapping on an exam glove. But he knows she’s modeled after the nurse on the cover of blink-182’s CD “Enema of the State.” It’s one of many asides he offers, making watching the rest of the skits a little like an episode of “Mystery Science Theater 3000.” He throws in facts about the disease being explained and personal tidbits. For instance, he tells me he graduated from Brigham Young University and divulges (off-the-record) his very high MCAT score. When society dean Robert Haynie sits down behind us, Norton asks a Hepatitis C-related question about the liver.
During an interview a few days later, Norton jumps quickly from subject to subject. He e-mails later and apologizes if he seemed annoying or obnoxious. He was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) when he was young, he says, and the tendency to ramble and chat comes along with it.
“Long-story short, don’t hesitate to tell me to can it if I won’t shut up,” he writes. “I won’t be offended; in fact, I’ll probably have been telling myself to be quiet for a while already.”
As many as one-third of the first-year students fail Biochemistry.
That’s what some second-year students are saying. It’s really only about 10 percent, according to William Merrick, Biochemistry committee chair. But one-third is what the first-years have heard, solidifying Biochem’s reputation as the boot camp of medical school.
There’s no way to keep up with the reading on the body’s chemicals and processes. Students are holed up in E301 for several hours a day getting molecules and biochemical pathways thrown at them, trying to follow the lessons of a parade of Ph.D.s wielding pointers. Beta oxidation, energy metabolism, ionic configurations of amino acids. All the new nomenclature and methodology. It’s a grind.
On the first day, Merrick, mustachioed with arched Jack Nicholson-like eyebrows, reminds them that they should consider themselves “physicians in training.” They should “act accordingly,” “behave professionally” and dress for class as if they were going to see patients.
“We don’t want to have you caught in the transition between panty raids and diagnosing cancer,” he says before giving the floor to the faculty member teaching the thermodynamics of energy metabolism.
At Case Med, subjects are taught in “committees,” courses designed and taught by groups of faculty members. Biochem is where it becomes obvious to Marleny Franco that this is a transition year. To help make time for students to complete a research thesis, material that used to be taught in the second year will be taught in the first. As a result, the Biochem committee had to compress the material that it used to teach over five weeks into three and a half — warp speed to Franco, who hadn’t encountered much Biochem as an undergraduate community health major.
Dr. Terry Wolpaw, associate dean for curricular affairs, says reducing the amount of “passive” learning, such as lectures, is a trend in medical education and one feature of the new curriculum.
The 2006 first-year students will carry much more of the educational burden in more small-group sessions, which will include more integration of subject matter.
That first week of Biochem, however, Franco isn’t thinking of big-picture curriculum changes; she’s stewing over the fact that second-years had more time to learn Biochem, and she’s trying to figure out how to study it herself.
She gets so little sleep that she starts nodding off in class. The week before the exam, Franco pulls several all-nighters at the school, sometimes napping in the lounges. She’s not fully awake when the exam starts at 8 a.m.
She begins with the short answers because the first question seems easy. The second is harder. The third harder still. One question involves the process of cholesterol synthesis — something she taught another student several hours earlier. But she can’t remember it now.
She falls asleep and wakes up when her head hits her desk. She goes to the bathroom and splashes water on her face. She still can’t remember cholesterol synthesis. She works on the multiple-choice section. When it’s noon, she turns in her unfinished test.
Afterward, the student she helped understand cholesterol synthesis thanks her. She doesn’t tell him she forgot it herself.
This is what she does remember: The orientation-week lecture about failing a committee, how the whole room went silent as the remediation process was explained.
Franco knows that if she failed, she’ll have to keep studying Biochem, while trying to learn the same new material as the rest of the class. Eventually she’ll have to take another Biochem test.
She walks over to her desk in the “green room,” one of the cube farms on the third floor. Taking a deep breath, she flips open her laptop again and checks how she did on the multiple-choice section.
It’s not until after she walks home and climbs the stairs to her room that she begins to cry.
Along with the science of medicine, medical students have to learn the art of touching patients.
It’s the job of Dr. Seymour Liberman, a retired internist, to teach the first-years how to use their hands as well as their heads.
“What’s a pulse?” he asks them.
When no one answers, he explains that the pulse is a wave set off by the heart, and “you can feel the pulse in the area where the arteries are close to the skin.”
Throughout the room, hands move to wrists, to necks, feeling for the beat under their own skin.
“You are very lucky the university has a course like this,” Liberman says in his somnolent voice. “Anatomy’s good. Physiology’s fine. But you really want to get your hands on the body.”
Liberman asks for a volunteer, then he feels for the carotid pulse in the young man’s neck, the brachial pulse in the crook of his elbow and the femoral pulse in his groin. Liberman tells the students to always examine from right to left (“because that’s the way I learned it”) and use three fingers instead of two (“because you’ll have a better chance of finding the pulse”).
Liberman continues examining the volunteer, peppering his monologue with medical terms followed by, “Do you know what that is?”
He answers more of his own questions, never making the students feel stupid for not knowing.After the pulse, he shows them how to take a blood pressure.
The students then pair off and head to patient rooms to practice taking each other’s history, pulses and blood pressures with fourth-year medical students.
In a tiny room where one piece of artwork competes for wall space with a busted clock and a hand-sanitizer dispenser, a fourth-year student introduces herself as Katherine. Her ice-breaker question for Mike Norton and David Svec is, “So did you go to the Biochem party?”
Svec did. Norton did not.
Norton is the doctor first. He knocks on the door, sits down, introduces himself and asks what brings Svec to his office.
“Pain in my knee,” Svec says.
“Describe the pain,” Norton says.
“I notice it when I’m running.”
“Have you seen a doctor for it before? Have you taken anything for the pain?”
“What kind of pain? Is it sharp? Is it in the skin? The bone?”
When they’re done, Svec says Norton questioned him more thoroughly than the doctor he saw for the condition. At one point when they’re talking about the importance of asking questions, Katherine mentions that she’s going into child psychiatry.
“One psychiatrist [he saw for ADHD] tried to diagnose me with bipolar disorder,” Norton says. “I’ve got the manic, not the depression.”
Awkward silence. Norton’s wife, Kate, his social barometer, usually has to tell him when his audience suddenly wants to change the channel. But she’s not here.
They move on to taking each other’s blood pressure. The subject of Norton’s misdiagnosis fades to the sound of blood pushing against artery walls.
When Norton and his wife first moved to Cleveland, they didn’t have health insurance.
In Provo, Utah, they were insured through Myriad Genetic Laboratories, where Norton was working on screening tests for genetic mutations that predispose people to breast, ovarian and colorectal cancers. But the Nortons thought the family medical plan Case offered was too expensive at $3,244, and it wouldn’t cover Kate’s pregnancy, which it considered a pre-existing condition. So for $910, they bought the single student plan just for Norton, making Kate, nearly seven months pregnant and unemployed, eligible for Medicaid.
It wasn’t an easy decision to go on public assistance. Although Norton grew up middle class, his parents always struggled. (He didn’t realize ramen noodles come in more than the two flavors Costco carried until he was in college.) At 19, he went to Brazil on a religious mission, which is expected of Mormon men. He spent most of his time with the poor, which deepened his compassion for them.
Socially and politically, though, Norton is a conservative. He doesn’t consider health care a right, but a privilege “I’m going to extend to everyone I can.”
He does realize, of course, that it’s getting harder to be that kind of doctor. Insurance companies are limiting options. Reimbursements to health-care providers are shrinking. Doctors have to squeeze in more patients, whom they have less time to see and get to know.
But as a physician, a cardiologist perhaps, he is determined to follow his conscience.
On Medicaid, it takes Kate three weeks to get an appointment with an obstetrician, making it six weeks between checkups. When Kate finally gets an appointment in mid-September, they both are relieved to hear that everything’s fine. When she goes into labor on a Thursday afternoon two weeks later, Norton’s glad she can deliver at University MacDonald Women’s Hospital, right next to the medical school.
She’s in labor throughout the night and the next morning. By the time I arrive, around 1:30 p.m., she’d been pushing for an hour.
Norton comes out of the room looking exhausted, his clothes rumpled and his hair flat. (He says he forgot the hair gel he uses to keep it spiky on top, and, even worse, his deodorant.) But his look is calm, his voice steady.
“We’re close,” he says with a slight smile.
I confess my excitement for them. As he’s walking away, I tell him how well he’s holding up.
He stops and shoots me a look of disbelief. “I’m scared to death,” he says. Then he rushes back down the hallway.
The calmness on his face is a mask, a really good one. Already, Norton emanates confidence without being able to feel it. I always thought
12:00 AM EST
July 31, 2006