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White Coat Hypertension

Author’s note: The following was presented at the University of Rochester’s Class of 2021 White Coat Ceremony.

The day before I was asked to give this speech, sometime mid-May, I was speaking with a first-year student. At the time, I was two weeks shy of completing my third year of medical school — the year of school that you spend the most time in the hospital. I had spent the year helping to deliver babies, hold end-of-life conversations, amputate limbs. It was totally amazing. By the end of the school year, I felt that I was pretty decent at being a medical student, that I had gotten my sea legs. And yet, when the first-year student asked me, “At what point does the white coat stop feeling like a costume?” that day, I responded, truthfully, “Not during third year — but maybe later?”

Maybe some of you are familiar with the term “white coat hypertension,” where patients’ blood pressures jump up in doctors’ offices because they’re anxious. In welcoming you to med school, I would like to introduce you to another form of white coat hypertension — that is, the constant anxiety that, although there is an expectation that you are a health care provider (or that you will be one soon enough), you won’t have the right instincts in an acute situation or that you will unknowingly give a patient misinformation or worse. This anxiety is rarely all-consuming, but it is almost omnipresent. And you will each experience it differently, by virtue of your prior experiences, or perhaps your mentor’s, or gender or race. My best guess is that what I’m describing will be familiar to all of you if it is not already.

So, back to this past May. I was rounding out the end of spending four weeks on the pediatric hematology-oncology unit — which, as a disclaimer, is not nearly as depressing as you might think (although this story is conventionally depressing). There were several patients that stuck with me, but there was one in particular that I felt closest to, when I went home, when I ate lunch, when I brushed my teeth. He was a preteen with advanced cancer that had undergone multiple chemotherapies and surgeries without success, and he came to Rochester to participate in a clinical trial, leaving behind all of his friends and much of his family. He hated reading and liked drawing animals.  He was exasperatedly in love with his girlfriend of two years who sent him a necklace with their initials, huge and bejeweled, while he was in the hospital. He played merciless pranks on his nurses. But throughout all of this, he was sick, tired and in profound physical pain. He was scared of dying and beginning to shrink from living, and he told me that he could not bring himself to share this with his family because he could not bear to cause additional heartache. While I was on my month-long rotation, he was admitted a total of three times due to progression of his disease. One night, he awoke to his monitors screaming and three nurses staring at him wordlessly, watching the rise and fall of his chest after he had undergone surgery to create scar tissue to attach his lung to his chest wall, a tube peering out from under his rib to drain blood into a small, bubbling machine. He confided in me that he was convinced he would die then and that his care team was too afraid to tell him so. He felt better a few hours later, but with each admission, he grew angrier, and his mother more desperate.

The family would seek me out to ask questions. I rationalized that this was because I was a familiar face to the family because I could already recite his medications and allergies. Some of these questions were about side effects or surgeries, which I could comfortably address at this point in my training. Some concerns were thornier and more nuanced, and I could acknowledge that I was becoming a larger part of their care. But what I could not accept, initially, was that they trusted me. They genuinely believed that I could tell them the truth — and the right amount of the truth — and communicate all of that within the friable shadow between a terminal disease and its most aggressive treatment. Like a real doctor. Those skills are terrifying, but they are magnificent. In the end, reflecting on my time with this family finally pushed me to accept them.

This was the source of my white coat hypertension. Responsibility is not only about competence, but also about promises. All of you will be invited into patients’ lives — sometimes deeply and sometimes in passing, but always intimately. By accepting that invitation, you make a promise — a social pact, yes, but also something more personal, and an obligation, yes, but also something given earnestly — that you will do your best to protect them. At its best, the white coat is shorthand for that promise. In wearing it, you do not guarantee perfection, but you do guarantee sincerity. In wearing the coat, your badge, your position — whatever the signifier may be — you wear a reminder to yourself and to your patients that you have chosen to give what you can, keep learning for a lifetime and grow without coming unrooted.

So with that: Congratulations on your achievements thus far, Class of 2021, and welcome! You have so much to look forward to.

Ria Pal, MD Ria Pal, MD (11 Posts)

Former Editor-in-Chief (2017-2018) and Former Medical Student Editor (2016)

University of Rochester School of Medicine and Dentistry

Ria is a Class of 2018 medical student. She graduated from the University of Rochester with a BS in neuroscience. Her interests include human behavior, social justice work, art, public health, and mnemonics.