PERSPECTIVE

The Doctor's White Coat

The Image of the Physician in Modern America

DAN W. BLUMHAGEN, M.D.; Seattle, Washington

The social perception of the physician has changed during ally going on here," to direct each actor's behavior, and
the past century. This is reflected in the changing use of a to express the dominance relationships that exist between
symbol of the profession, the white coat. This dress
the various individuals who are interacting. Since most
originated in operating rooms, scientific laboratories, and
modern hospitals, each of which contributed to the social symbol analyses have dealt with small-scale preliterate
understanding of what it means to be a healer. Adding the societies, there is no well-defined formula for doing such
cultural significance of "whiteness" reveals a broad a study in a complex, literate society such as modern
spectrum of meaning surrounding the healing encounter, America. My approach here will be to look at doctor-pa-
whose most important aspects are the authority and
supernatural powers of scientific physicians and the tient interactions to determine what symbols may be
protection of patients. A major force aiding in the used, then to examine historical data documenting how
adoption of this symbol was the shift in sick care from these came into use and the original meanings they bore.
home to hospital, where it served to legitimate otherwise Finally, the use of these symbols in the medical setting
socially taboo behavior. Recent changes in how scientific
medicine is publicly viewed have eroded these established
will be compared with similar symbols used in other
meanings. The resulting tensions affect individual patient- American rituals to develop the full spectrum of meaning
physician encounters and interactions between the that they communicate.
profession and society as a whole.

Symbols of the Physician

A L L SOCIETIES have healers who care for the sick (1).
What, then, are the symbols surrounding physicians,
The healer's interaction with a patient is often surround-
and what do they mean? Table 1 shows how physicians
ed by a symbolic system that expresses the implicit cul-
are depicted in advertisements for medical journals and
tural concepts of what "healing" means (2). As changes
in newspaper comic strips. These sources were chosen
occur in the social meanings attributed to healing, the
because they represent stereotypes of the doctor as pre-
symbols used to express those concepts also change. This
sented to the profession and to the public. They represent
paper will use the symbol-analysis approach, widely used
"all physicians in general" and do not merely reflect the
in cultural anthropology, to examine the historical ori-
idiosyncracies of a particular physician.
gins and the function of the symbol systems that sur-
round American physicians and their patients. An under- Table 1 shows that although there are some differences
standing of how these were adopted first by the profes- in the way physicians are depicted in medical and popu-
sion and then by the greater society will elucidate what it lar media, there appear to be four principal objects used
means to be a healer in American culture. This knowl- to depict the doctor: the white coat, stethoscope, head
edge can be usefully applied to problematic patient con- mirror, and black bag. In this survey, there was only one
sultations, as well as to understanding some of the con- physician depicted in a patient-care setting who did not
flicts that have arisen between the medical profession and have at least one of these items. The most frequent com-
society at large. ponent of the image seems to be the white coat. Of 43
doctors pictured in patient-care settings (Table 1), 36
The Nature of Symbol Analysis were wearing white. In the symbolism of white coats, the
social concept of "what it means to be a physician" is
Most physicians are aware of the importance of symbol
summarized, intensified, and extended (Figure 1). Its im-
analysis in individual psychotherapy (3). What is less
portance as the symbol of physicians is seen in that when
widely appreciated is the application of a similar ap-
the advertising media—a reflection of the current social
proach to understanding entire cultures. Anthropologists
stereotype—wish to depict a person with the authority of
have found that symbols are often used as a way to ex-
a physician, he is usually shown wearing a white coat.
press and reaffirm the fundamental belief systems that a
Although professionals are reluctant to articulate the
society holds (4). This is often done in ritualized events.
meanings they attribute to white coats, on occasion, un-
Perhaps cultural symbols can be most usefully viewed as
der stress, such interpretations may be given.
a form of communication, analogous to words in a natu-
ral language (5). Like words, they can be used in social The relationship between a physician and his patient is
settings to define the shared interpretation of "what's re- serious and purposeful, not social, casual or random. In
this relation the patient unburdens himself or herself of a
• From The Robert Wood Johnson Clinical Scholars Program, University of set of concerns regarding health matters and transfers
Washington; Seattle, Washington. them to the accepting physician. For a very long time it
Annals of Internal Medicine. 1 9 7 9 ; 9 1 : 1 1 1 - 1 1 6 . © 1 9 7 9 American College of Physicians
in

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 Table 1. Depiction of Physicians in Medical and Lay Media resurrect the patient, healed.
I have said that the modern surgeon has become a popu-
Medical Newspaper lar hero . . . . One has only to glance through the month's
Journals* Comicsf illustrated magazines, or to turn a few pages of the latest
novel to find him in the act of revealing his demonical
Number 45 11 subtlety or demonstrating his incredible skill. The tall
White coats 29 7 spare frame is capable on emergency of strength and en-
Stethoscopes 13 5
durance that would make Sandow stand aghast (8).
Head mirror 6 5
Black bag 0 5 White coats had not yet become symbolic of this hero-
No special identifiers 14J 0 ism, but the newly developing film industry ground out a
remarkable number of amplifications of this theme (9).
* Advertisements showing individuals clearly identified as physicians that ap- One such film, "Society Doctor," is described as being
peared in JAMA. 1978;239( 1-5); N Engl J Med. 1978;298( 1-4); Am Fam "played in spotless white . . . and with an appropriate
Physician. 1977-8;16(6) to 17(2); and J Fam Pract. 1977-8;5(6) to 6(2). Each
illustration was counted once, regardless of how many times it appeared. sense of glamor and nobility [The hero] persuades
t Syndicated comic strips that ran in the Seattle Times and Seattle Post-Intelli- his best friend to operate on him, directing the work him-
gencer in January 1978. Each individual identified as a "physician" or "medicine
man" was counted once, regardless of how frequently he appeared in a single strip. self with the aid of mirrors" (10). In these quotations we
X Two advertisements that show "clinical experts" making decisions about drug see that the social image of the physician had become one
use or continuing medical education, that is, decisions that would affect the
physician's behavior rather than the patient's, account for 13 of these. of immense power and authority. These attributes were
associated with the white clothing he wore.
has been customary for individuals in society to dress Even though the operating room provided one of the
rather formally when conducting serious business, and earliest examples of doctors wearing white, and provides
less formally when they are at leisure. The physician's some of the basic cultural meaning, it does not appear to
dress should convey to even his most anxious patient a
sense of seriousness of purpose that helps to provide reas- be the main source. Stand's otherwise valuable article
surance and confidence that his or her complaints will be (11) confuses this point. With the goal of better aseptic
dealt with competently. True, the white coat is only a technique, the white coats of 1889 rapidly became full-
symbol of this attitude, but it also has the additional length gowns, and were referred to as such (12). Aseptic
practical virtue of being identifiable, easily laundered, surgery required that these gowns only be used in the
and more easily changed than street clothes if accidental-
ly soiled . . . . Casual or slovenly dress is likely to convey, operating room to avoid the risk of cross contamination.
rightly or wrongly, casual or inattentive professional han- The back opening, a necessity for sterile technique, also
dling of their problem. Such a patient may respond in an made it impractical for other patient-care settings (11).
inhibited manner, fail to volunteer information, refuse to Additionally, the term "gown" in our culture usually re-
carry out a recommended diagnostic or management pro-
gram, fail to keep appointments, and be uncomfortable fers to women's clothing, and thus is not suitable as a
enough to seek help elsewhere. The rapport, so anxiously symbol for those who were "active, scientific men, virile,
sought for with your patient, may be irretrievably lost ambitious . . . upon whose shoulders the actual work of
(6). the institution will fall" (12, p. 265).
To fully understand how the white coat has achieved Figure 2 clearly shows the divergence of white coats
this position, we must look at the historical origins of from operating-room gowns. There are three types of
white coats as the symbol of physicians. I have been able dress in the audience: the scrub suits of the surgeons who
to identify three major origins for the white coat as it has are clustered on one side; the street clothes of the vast
been used until fairly recently: the operating room, the majority in the middle; and the white coat of a single
scientific, specifically microbiological, laboratory, and the individual who looks as if he had just walked out of his
hospital. Each adds a layer of meaning. laboratory to observe the procedure. The step that took
the garb of the scientific laboratory into a clinical setting
The White Coat in the Operating Room appears to be the main source of our current white coats.
Operating-room garb appears to have originated with The term "lab coat," the primary term used for the white
the concept of aseptic surgery, which began in this coun- coat, refers to this origin.
try about 1889 (7). Photographs from that year in the
Massachusetts General Hospital Archives show the sur- The White Coat in the Laboratory
geons and nurses (but not the anaesthesiologist or observ- The representation of the physician as a scientist has a
ers in the balcony) wearing short-sleeved white coats over long history that culminated during the first decades of
their street clothes. Masks and gloves had not yet come this century. In the middle of the 19th century, science
into use. The purpose of the coats in this setting appears had nearly destroyed the reputability of medicine by
to be twofold: to protect the patient from being contami- demonstrating that its cures were worthless, but it was
nated by the physician, and to protect the physician from unable to substitute more effective remedies. Medicine
contamination by the patient during the procedure being became simply one of a wide variety of healing cults and
performed. We will find that the white coat repeatedly quackery (13). Despite this inauspicious start, both the
serves to protect both the patient and the physician. profession and public turned to science as the means by
Another implication that surgery has for the public which healing would come. After all, the laboratories,
image of the physician is its incredible power to send a whose inventions had transformed night into day, could
person into a deathlike state, open the previously inviola- transmit messages instantaneously, and had revolution-
ble body cavities, correct whatever was "wrong," and ized transportation, were certainly the most important
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 hope for the conquest of disease. Physicians were urged
to present themselves as scientists. Cathell, whose book
The Physician Himself went through many editions be-
tween 1882 and 1922, advised: "Show aesthetic cultiva-
tion in your office arrangement, and make it look fresh,
neat, clean and scientific" (14) [emphasis added]. Above
all, one must avoid "forcing on everybody the conclusion
that you are, after all, but an ordinary person" (14, p.
56). By 1922, Cathell had become more emphatic in de-
scribing "the office, the sanctuary—of an earnest, work-
ing scientific medical man . . . " [emphasis in original] as
the place where one will make "judicious and intelligent
use of your scientific instruments of precision . . . to assist
you in curing nervous and terrified people by increasing
their confidence in your armamentarium and in your pro-
fessional ability" (15). The authority of science is seen as
validating the practice of medicine.
Demonstrations of the efficacy of modern science, such
as the construction of the Panama Canal (1915), led to its
public acceptance as the foundation of modern healing.
An intense feeling of hope about the future of scientific
medicine was expressed in cartoons such as the ones in
Figures 3 and 4. Other healing cults, particularly home-
opathy and eclecticism, which had threatened the exis-
tence of scientific medicine only a few years earlier with-
ered away. Their schools closed or converted to biomedi-
cine.
The medical profession rapidly consolidated its posi-
tion as a part of the scientific enterprise. Within a decade
of the publication of the Flexner Report in 1910, medical
education was restructured around laboratory science. Figure 1 . The symbols of American healers. (Copyright 1 9 7 7 , U.S.
The content of medicine changed. Textbooks were rewrit- News and World Report, Inc.; used with permission.)
ten: Of all the books popular enough to go through multi-
ple editions before the "progressive era," almost none the use of personnel and resources that could not readily
were still being printed when it ended. (This was ascer- be taken to the patient's home. With the impact of the
tained by a review of the books in the open stacks of the change in medical care, the image of the hospital changed
Countway Library. The most notable exceptions, of from that of being a place where social outcasts died to
course, are Gray's Anatomy and Osier's Textbook of being the only place where the sick could be healed. The
Medicine (1892), both of which are still being printed in image changed from death to life. This was reflected in
revised editions. There were no technical or theoretical the change of the clothing of the healing staff. The black
advances that would outdate the former, and the latter habits of the religious nursing orders, for example, be-
was written by one of the men who led medical education came the white uniforms of the modern nursing profes-
during this change.) Towards the end of this radical sion (17). Hornsby, then director of Michael Reese Hos-
transformation of the profession of medicine, and as a pital in Chicago, tells us in The Modern Hospital (12, pp.
reflection of it, physicians became stereotyped as scien- 543-5) that all people connected with the healing process
tists wearing white coats. The message of power and pro- (including patients and visitors) were to be dressed in
tection emerge: While wearing a white coat the physician white, whereas the nonmedical employees were to be giv-
is able to handle safely the deadly scourges that plague en colored uniforms. White became associated with the
mankind and is able to render them innocuous. One re- institutions of healing, and it was within their halls that
sult of this perception of power was that physician-scien- the use of white coats as the symbol of medicine was
tists were granted tremendous authority. No mere indi- most pronounced. Physicians in private practice have
vidual desires or beliefs were allowed to stand in the way never completely adopted their use.
of the public's health as determined by medical laborato- This transition is most clearly indicated in the photo-
ries (16). graphs of house staff that often accompany a hospital's
annual report. These pictures show that during the peri-
The White Coat in the Hospital od 1905-15 apprentice physicians exchanged their street
The shift in locus of sick care from the home to the clothes for white coats and pants. Hornsby indicates that
hospital was the third historical trend. The basis for this this was not merely for the convenience of the hospital
lay in the development of aseptic surgery and modern laundry; indeed, "Intern's white uniforms are difficult to
diagnostic and therapeutic techniques, which necessitated launder, and should be done by hand" (12, p. 601). In
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 derived from the Latin candidus (white). This impartial
truth-telling is often portrayed in statues of "justice,"
who is usually depicted wearing white.
If symbols affect behavior, the use of the white coat
should affect how patients and physicians act. There ap-
pear to be two behavioral changes that have been mediat-
ed by the white coat: the physician's access to his pa-
tient's body, and the shift in the locus of the sick role
from the home to an institution.

Body and Sexual Taboos in American Culture

In many societies, the most powerful symbol systems
are found in situations where strong social values appear
to be challenged (20). One of the strongest beliefs in our
society is the inviolability of a person's physical body (21,
22). There is even a legal term for the violation of a per-
son's rights over his own body: battery. Merely touching
another individual without that person's permission is to
Figure 2 . The Society of Clinical Surgery, The Massachusetts Gen- be at jeopardy of civil and criminal action (23). The ex-
eral Hospital, May 1 9 0 8 . (Used with permission of The Massachu- tent to which the physical examination is a serious breach
setts General Hospital, Boston, Massachusetts.)
of social custom has been clearly stated by Lief and Fox
other words, there were compelling reasons for dressing (24).
interns in white that outweighed the economic disadvan- The amounts and occasions of bodily contact are careful-
tages. ly regulated in all societies, and very much so in ours.
The kind of access to the body of the patient that a physi-
The Meaning of Whiteness cian in our society has is a uniquely privileged one. Even
in the course of a so-called routine physical examination,
Given the historical backdrop of the meaning of the the physician is permitted to handle the patient's body in
white coat, what is added by the cultural conception of ways otherwise permitted to special intimates, and in the
the meaning of whiteness? Originally, laboratory coats case of procedures such as rectal and vaginal examination
were tan and appear to have changed to white as they in ways normally not even permitted to a sexual partner.
became associated with medicine. Why was not another, The physical body is not merely a threat to the person
perhaps more functional, color adopted? Why were both whose body is revealed, it is also considered to be danger-
the profession and the public so profoundly disturbed ous to the one who is exposed to it. This is the basis of
when Nobel Laureate Alexis Carrel wore black gowns in much of the American film rating system. Given these
his laboratories and operating rooms at the fledgling taboos, the perfunctory way that physicians are given
Rockefeller Institute of Medicine (18)? permission to do the most intimate examination is re-
The significance of white as a symbol of life has already markable.
been mentioned. Since there are few celebrations of life in The individual must stand before his doctor man to man,
our society, this meaning is derived from its opposite col- unclothed physically, mentally and morally, revealing to
or, black, which is clearly the color of death and mourn- him as he does to no other mortal, not even to his father
ing. The association with purity has also received com- confessor, the secrets of his inmost soul; submiting his
person to the most thorough scrutiny of the physician
ment. But this purity contains two strands of meaning: and to varied tests, physical, clinical, instrumental and
First is the concept of innocence. N o shadow of malice,
of intentional harm, can mar the white coat—the patient
is safe in the hands of this powerful figure. Second is the
purity of unaroused sexuality, particularly as this mean-
ing is evoked in another ritual that uses the white bridal
gown.
Closely allied to the concept of purity is the concept of
superhuman power. The saying "cleanliness is next to
godliness" originated long before the germ theory of dis-
ease! Whiteness as an attribute of superhuman power, at
once irresistibly attractive and infinitely dangerous, is
clearly expressed in Melville's Moby Dick (19) and, as
has been shown, was explicitly applied to physicians. In
religious symbolism, Christ and the saints who have exer-
cised their power over death and all other human frailties
are robed in white (Bible, Revelations 7:9-17) But these
are not merely powerful, they are supremely good. Figure 3. From How to Live: A Monthly Journal of Health and Hy-
A final meaning comes from the term candor, itself giene. November 1 9 2 5 ; 8 ( 1 1 ) : 1 .

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 what not, and without hesitation committing to his keep-
ing the keys of the family skeleton closet (25).
Physical examinations of apparently healthy people are
a relatively recent phenomenon. Referring to the late
19th century, Duffy writes: "Physical diagnosis remained
handicapped by the reluctance of patients, particularly
females, to bare their skins to the probing, palpation or
percussion of the physicians" (26). Rectal and pelvic ex-
aminations do not appear to have been frequently used.
As late as 1927, Richard Cabot, a prominent medical
educator, claimed that "it is not and should not be a part
of the routine physical examination to examine the rec-
tum" (27). Buttressed, however, by the successes of medi-
cine in improving public health, a campaign was waged
from 1922 to 1929 that promoted periodic physical exam-
inations as a means of improving the individual's health Figure 4 . From How to Live: A Monthly Journal of Health and Hy-
(28). These included pelvic and rectal examinations. giene. February 1 9 2 7 ; 1 0 ( 2 ) : 1 .
For this crusade to be successful, the cultural dangers
of the physical contact had to be muted. A mechanism the physician will dominate the setting.
was needed that would reinterpret an ordinarily taboo
activity into a socially acceptable, even desirable, one Developments from 1930 to 1960
(29). A set of symbols was needed to protect both the The above set of symbols appears to have been fully
doctor and patient in this dangerous setting. The white functional by the early 1930s and remained largely intact
coat, with its meanings of bilateral protection, purity, until recently. There were minor changes, such as the
goodness, and unaroused sexuality, was ideally suited for adoption of blue or green garb in operating rooms when
this task. In the less-threatening situation where a male high-intensity lighting made the glare from white drapes
physician examined a man, the white coat was all that unbearable, but these pastel shades did not conflict with
was needed: The patient was nude (30). When the physi- the underlying value system as black or red, for example,
cian examined a woman, however, a reciprocal symbolic would have.
dress was required, leading to the development of the Other practitioners found that some of the meanings
examination gown. In one of the early descriptions of communicated by the white coat were so overpowering
such a garment, the symbolic themes come out. Fisk (30) that it interfered with their practice. Pediatricians and
claims that this gown "gives the examinee a sense of pro- psychiatrists have discovered that this mark of authority
tection and lessens embarrassment." The disparate treat- has a tendency to overwhelm their patients, and they
ment of men and women could not be maintained, and therefore tend to wear pastel coats or normal street
soon men, too, were offered the protection of examination clothes. As has been noted, many physicians, particularly
gowns. those in private practice, did not adopt the white coat.
The second behavioral change was a shift in the con- Nonetheless, these trends did not affect the public image
cept of where it was appropriate to act sick (31). Previ- of what a physician should be. If anything, the beliefs
ously, of course, illness had been a personal drama played were intensified, as is evidenced by the meteoric rise in
in the bedroom, the most secluded, intimate, and protec- the funding of medical research after World War II,
tive area of the home. The physician could enter at the which resulted in the National Institutes of Health and
invitation of the family and be made privy to the physical much of the rest of the academic medical enterprise (33).
and behavioral secrets contained therein without violat-
ing any social norms. Only those unfortunate persons Current Trends
who lacked a protective home sought care in an institu- During the past decade, however, much of this has
tion. It was only the "fallen women who enter hospitals" changed. Physician-scientists who were once seen as vali-
(32), that is, only those people without anything worth dating medical practice no longer necessarily protect and
concealing or without anyone to shield them. Symbols heal patients, but may endanger them. A good example
were required that would protect patients from the un- of this attitude is seen in the widespread laetrile move-
warranted intrusions that could occur in an institution ment, which is perceived as a direct assault on the
and that would legitimize private behavior in a public biomedical establishment. Other social symbols of au-
place. The physician's white coat and the patient's exami- thority are also being rejected. Hospitals are often ac-
nation gown met these needs perfectly. cused of prolonging agony rather than renewing life.
These shared meanings direct patient and physician be- Body taboos do not seem to be as strong as they once
havior in the following way: The physician is an active were.
scientist, the patient is passive material; the physician These social changes strike at the heart of the mean-
prescribes, the patient complies; the physician is self-con- ings communicated by white coats. N o new consensus
cealing, the patient is self-revealing. Clearly, as long as has developed that will define the nature of healing and
this social definition of the healing encounter exists, give direction for patient behavior. This has had an effect
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 on the use of both white coats and examination gowns. thropology. New York: Macmillan Publishing Co.; 1977:1.
2. KLEINMAN AM. The symbolic context of Chinese medicine: a compara-
The quote from Kriss (6) earlier in this paper that ex- tive approach to the study of traditional medical and psychiatric forms
pounded the significance of white coats is the result of of care in Chinese cultures. Am J Chin Med. 1975;3:103-24.
widespread student challenges of the authority of this 3. FREUD S. The Interpretation of Dreams. New York: Macmillan Pub-
lishing Co.; 1900.
symbol. Debate over whether medical students should 4. DOLGIN JL, KEMNITZER DS, SCHNEIDER DM. Symbolic Anthropolo-
wear one still continues (34). Voices from some of the gy: A Reader in the Study of Symbols and Meaning. New York: Colum-
bia University Press; 1977:3-47.
countercultural movements recognize the implications of
5. LEACH E. Culture and Communication: The Logic by Which Symbols
this symbolism and reject it. Some feminists, for example, Are Connected. Cambridge: Cambridge University Press; 1976:10.
"advise women to discard the drape by throwing it on the 6. KRISS JP. On white coats and other matters. N Engl J Med.
1975;292:1024-5.
floor when the doctor enters. If he replaces it, throw it on 7. POTTER RA, ed. Surgery in the United States. The American College of
the floor again" (35). This type of symbolic action tends Surgeons and the American Surgical Association; 1976:17.
to make physicians uncomfortable, for the rejection of 8. WHITBY CJ. The Doctor and His Work. London, Swift and Co.;
1912:23.
symbols of established roles means that there is little 9. SPEARS J. The doctor on the screen. Films in Review. 19 November
guidance as to how they or their patients should act. 1955;6:436-44.
Cousins (36) comments on this redefinition of roles in 10. New York Times Film Review: 1913-1968: Volume 2, 1932-1938. New
York: New York Times; 1970:1143.
the healing encounter when he claims that "the most im- 11. STAHEL HR. Der weisse Mantel in der Medizin. Zurcher Medizinges-
portant thing happening in American medicine today is chichtliche Abhandlungen 1970;78:1 -22.
12. HORNSBY JA, SCHMIDT RE. The Modern Hospital. Philadelphia: W. B.
not the discovery of magical new drugs but the new rela- Saunders; 1913:543.
tionship that is emerging between physicians and pa- 13. SHRYOCK RH. The Development of Modern Medicine. New York: Al-
tients" (36). The old model of the scientist-healer is re- fred A. Knopf, Inc.; 1947:248-72.
14. CATHELL DW. The Physician Himself and What He Should Add to the
jected for a more humanistic relationship. He continues: Strictly Scientific. Baltimore: Clishay and Barley; 1882:10.
"Traditionally the doctor is the authoritarian figure . . . 15. CATHELL DW. Book on the Physician Himself From Graduation to
the new relationship is more in the nature of a partner- Old Age. Emerson Hotel, Baltimore: Published by the author; 1922:10.
16. ROSEN G. A History of Public Health. New York: M D Publications;
ship." Note that the "traditional authoritarian figure" is, 1958:464-78.
as has been documented here, a tradition that has only 17. DIETZ LD, LEHOZKY AR. History and Modern Nursing. Philadelphia:
F. A. Davis; 1967:168-73.
existed since the turn of the century. There were reasons
18. CONNER GW. A History of the Rockefeller Institution. New York:
for adopting that role at the time: there may be similar Rockefeller Foundation; 1964:154.
reasons for abandoning it now. 19. MELVILLE H. Moby Dick, or The White Whale. New York: The Mod-
ern Library; 1930:272-83.
The dynamic relationship that exists between physi- 20. BERGER PL, LUCKMANN T. The Social Construction of Reality. Gar-
cians and American culture is only beginning to be ex- den City, New York: Doubleday and Co.; 1966:96.
plored. As we learn more about the social meaning and 21. MINER H. Body ritual among the Nacirema. In: SPRADLEY JP, RYNK-
IEWICH MA, eds. The Nacirema. Boston: Little, Brown and Co.; 1975.
function of healing, we will better understand some of the 22. GLASER BG, STRAUSS AL. Awareness of Dying. Chicago: Aldine Pub-
conflicts that we feel between society and the profession. lishing Co.; 1965:162.
23. BLACK HC. Black's Law Dictionary. St. Paul, Minnesota: West Publish-
This in turn may enable us to devise better institutional ing Co.; 1957:193.
and individual means of meeting these needs. But even 24. LIEF HI, F o x RC: Training for detached concern in medical students.
before that global understanding is reached, there may be In: LIEF HI, LIEF VF, LIEF NR, eds. The Psychological Basis of Medi-
cal Practice. New York: Harper and Row; 1963:32.
benefits that accrue on a smaller scale. In all patient-phy- 25. FINNEY JMT. The Physician. New York: Charles Scribner and Sons;
sician encounters, careful consideration of the symbolic 1923.
and other nonverbal communication may be important. 26. DUFFY J. The Healers. New York: McGraw-Hill; 1976:232.
27. CABOT RC. Physical Diagnosis. New York: William Wood anc1 Co.;
In particularly unsettled interactions, painstaking, explic- 1927:435.
it discussion and negotiation on the exact role that the 28. ROSEN G. Preventive Medicine in the United States, 1900-197x New
patient and the physician will take may be required for York: Science History Press; 1975:59.
29. EMERSON JP. Behavior in private places: sustaining definitions of reality
healing to occur. in gynecological examinations. In: DREITZEL HP, ed. Recent Sociology:
No. 2, Patterns of Communicative Behavior. New York: Macmillan
ACKNOWLEDGMENTS: The author thanks his colleagues who read and Publishing Co.; 1970.
commented on earlier drafts of this paper, especially Pamela Amoss, Arthur 30. FISK EL, CRAWFORD JR. How to Make the Periodic Physical Examina-
Kleinman, Thomas Inui, and James LoGerfo, all from the University of tion. New York: Macmillan Publishing Co.; 1928:41.
Washington. 31. FREIDSON E. Profession of Medicine. New York: Harper and Row;
This work was supported by The Robert Wood Johnson Clinical Scholars 1970:220.
Program. The opinions expressed herein are those of the author and do not 32. TROUSSEAU A. Clinical Medicine Lectures. Philadelphia: Blinkerston;
necessarily reflect those of The Robert Wood Johnson Foundation. 1882:43.
33. BORDLEY J III, HARVEY AM. Two Centuries of American Medicine:
• Requests for reprints should be addressed to Dan W. Blumhagen, M.D.; 1776-1976. Philadelphia: W. B. Saunders; 1976:419.
The Robert Wood Johnson Clinical Scholars Program, University of Wash- 34. M C K I N N O N JA. Life in a short white coat. New Physician. November
ington, Varsity Apartments, HQ-18, 3747 15th Avenue N.E.; Seattle, WA 1977;26:24-30.
98195. 35. DREIFUS C, ed. Seizing Our Bodies. New York: Random House;
Received 5 September 1978; revision accepted 19 April 1979. 1977:266.
36. COUSINS N. "A Better Rx for Patients." Los Angeles Times Syndicate;
2 April 1978. Syndicated editorial column.
References
1. LANDY D, ed. Culture, Disease and Healing: Studies in Medical An-

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