By Dr. John M. Livingston | Medical Policy Adviser

I have noticed over the past 12 years that a very small number of physicians have posed, in their white coats, with politicians. There are more than 3,000 physicians practicing in Idaho today and when a small group — five or so — pose in the Capitol building in their white coats the general public may believe that this small group speaks for the medical profession as a whole.

Nothing could be further from the truth.

The majority of the 3.000 Idaho physicians are working so hard seeing patients that they don't have time to take off from their practices to testify or demonstrate at the Capitol.  Physicians, by nature, are not politically active. Most believe that the duty to patients is a responsibility to patients — particularly sick patients — and not to a political cause.

In 2009, I was in Washington, D.C., representing the American College of Surgeons on their executive committee when I was asked if I wanted to meet President Barack Obama. I said of course I did, but when I got to the White House, I was told that there was a white coat waiting for me to pose in the Rose Garden with the president.  I, along with the majority of my colleagues, walked out of the ceremony prior to its even starting. We refused to allow a symbol of the medical profession to be used for political purposes.

I believe that many of the people posing in their white lab coats don't understand the history of the coat. They may also not understand that in allowing politicians to lever a symbol of their profession, they are in fact demeaning the values represented by that symbol.

Interestingly, American physicians did not start wearing white coats until the late 1890s.  There are some specialties that do not wear the coat today because they believe that the authoritative connotation of that symbol may interfere with the doctor-patient interaction. For instance, pediatricians seldom don the white lab coat.  

For most medical students at the mid-portion of their first year of medical school, they participate in a ceremony where they first put on the white coat. Usually, a family member, spouse, parent, a respected teacher, or mentor is given the honor of helping that student first put on the coat. It is believed in our country that the white coat, in its various styles, had its origins at John Hopkins with Dr. William Osler, often venerated as the "father of Internal Medicine.” Medical students at Hopkins wore short, white coats that looked more like a sport coat. Residents and interns wore coats that extended to the mid-thigh.  Staff and attending physicians wore long coats that extended to mid-calf. In addition to identifying the wearer of the coat as a caregiver, it also defined their status and level of authority and responsibility.

Prior to the establishment of John's Hopkins, caregivers wore black uniforms. Surgeons and physicians wore suits. There is a very famous painting called "The Gross Clinic" about an amputation done at the University of Pennsylvania hospital where all the surgeons in the operating room are sporting black formal attire. Catholic Sisters wore black habits attending to patients on the "Alms wards" until around 1900.  

During my own white coat ceremony more than 40 years ago, Dr. Hutch Williams at Ohio State University warned the first-year medical students that the white coat was a symbol of the fidelity of the clinician to the patient. In his talk, he specifically pointed out that lawyers, bankers, and politicians don't wear white coats. He warned us to always be a doctor when you wear the coat.

You were not to wear the coat, he advised, when attending church or working in a business office. You were not to wear the coat, for example when attending a hospital board meeting, because your responsibility at that meeting was to many patients in your community, not to your patient. You were not functioning as a doctor clinician in those situations. At academic ceremonies like commencements, doctors wear academic garb, not white lab coats. That denotes they aren't serving patients at academic processions. I would argue that when a doctor participates in the political process, she should not wear a white lab coat.

I have testified on numerous occasions before legislators. I sit on the state health insurance exchange board. I never wear my white lab coat except in a clinical setting. Let's remember when a small group of physicians at the Capitol present themselves publicly outside a clinical

patient care setting, we need to understand two very important things.  They are an extreme minority — around 1/1000 physicians. The others are serving patients.

We also need to understand that maybe they are, in fact, representing a special interest group like the Idaho Medical Association, the Idaho Hospital Association, or a hospital where they are employed. No matter what, in my opinion, they are trying to leverage their special position as a caregiver for political and economic purposes.

Next thing you know we will see hospital administrators, chief financial officers, and the chief executive officer heads of the IMA and IHA parading around the Capitol in white lab coats trying to score political points. It's not illegal. Anyone can wear a white lab coat.

There is irony here.

The Latin word for white and pure is candidos from which the words candor and candidate come from.  In ancient Rome, candidate legislators wore white togas symbolizing candor and truth. We probably won't be able to get our legislators to wear white togas and tell the truth (maybe we could get IACI and some other lobbyists to chip in), or better yet arrange for a toga party at Sun Valley to be paid for  by the lobbyists with any extra money being put in a "scholarship" fund or used to build new office space or our representatives.  

What I have learned in the last four years of the debate about Medicaid and Medicaid expansion is that most political rhetoric purposefully tries to provoke emotion, when good political and economic policy requires empiric logic and discernment.

In the end, I guess if you wear a white lab coat and support Medicaid expansion, you are more caring and empathetic than someone like me who doesn't try to leverage a privilege and exploit those on the margin.

I have always believed that it is an obligation for all of us individually to take care of those on with chronic diseases who cannot take care of themselves through no fault of their own. But when we also take on the burden of subsidizing healthy people, we will limit access for those in need and who are in the traditional Medicaid population. Isn't it interesting that those most in need who Medicaid was designed to help first never testified before our Legislature? They are the ones who will be hurt by expansion.

Where are the white coats looking after those patients? They are busy at work in clinics and hospitals, not lobbying.

Maybe next year the IMA and IHA can buy white coats for naive physicians that under their name and MD will have a monogrammed lobbyists tag on it.

I have some designs in mind for those interested.