White coats are everywhere in Boston's academic medical centers, a universal sign that the wearer is a medical professional. But look closer, and you will notice that not all white coats are alike.
There are long coats, and there are short coats. And who wears what is sometimes a sign of their position within a hospital's hierarchy.
Most medical students, who are sometimes called "short white coats," wear hip-length coats that are bestowed upon them in a solemn ceremony when they begin medical school. The short coats indicate they are not yet doctors, who at most of the city's teaching hospitals wear knee-length white coats.
If patients notice the difference, they typically don't know what the lengths mean. But attire has a significant history within the profession. At some hospitals, doctors have held meetings about coat length. And occasionally residents -- junior doctors who have graduated from medical school but have not completed on-the-job training -- protest the short coats they are expected to wear.
"These are byzantine and complex decisions," said Dr. Mark Zeidel, physician in chief at Beth Israel Deaconess Medical Center. "It doesn't seem like it should be a big deal, but it matters to some people."
Adding to the complexity is that the practices regarding white coats differ among hospitals and even within hospitals, because there are few rules, just traditions. At every hospital, there are physicians who break from tradition, for reasons of fashion, practicality, or something deeper. Many nurses, technicians, and other staff now wear long coats, too. Of course, all staff must wear nametags that identify their job.
Residents generally wear short coats at Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, but knee-length coats at Tufts-New England Medical Center. Even at these hospitals, however, some residents have started wearing scrubs, the loose-fitting, pajama-like outfits once used mostly by surgeons, rather than coats. Most senior doctors, called attending physicians, wear long coats, except at Massachusetts General Hospital. There, the strong tradition for doctors is short coats just like those worn by medical students; older physicians theorize that this unusual formulation was adopted to symbolize that Mass. General doctors are learners for life. The eminent institution buys nearly 9,000 white coats a year.
Dr. Mark Aronson, one of the few attendings in medicine at Beth Israel Deaconess who wears a short coat, said he received a note from one of his residents a year ago complimenting his choice, saying it set an example of a doctor always being a student.
Senior doctors said the white-coat custom, of any length, probably developed because physicians at academic medical centers traditionally have done research in addition to treating patients, and needed the coats to protect their clothing from laboratory chemicals.
The dress codes for residents and doctors at the nation's teaching hospitals used to be far stricter, and as recently as the 1970s residents at some Boston hospitals were required to wear white coats and white pants starched in the hospital laundry.
Dr. Eugene Braunwald, now a distinguished senior physician, required residents to wear white coats at meetings during the 1980s, doctors who trained under him said.
Braunwald "felt it was part of professionalism," said Dr. Richard Schwartzstein, a resident then and now a pulmonologist who is vice president of education at Beth Israel Deaconess. The chief resident kept several extra short white coats in his closet for those who forgot theirs, he said.
In the 1990s, the Arnold P. Gold Foundation, a nonprofit started by a physician and his wife to promote "humanism in medicine," popularized the white-coat ceremony at medical schools, during which the dean or hospital president personally places the short white coat on the shoulders of each student "to carry on the noble profession of doctoring." Now, more than 90 percent of US medical schools hold the ceremony.
Coat length matters for Siqin Ye, 27, a first-year resident at the Brigham who wears a short coat, but not because of the status it might suggest. He went to medical school in Chicago, where residents wore long coats.
"I have actually thought a great deal about this," he said. "When I came here, it was very confusing. What we [residents] object to about short coats is that they're not very fashionable. It doesn't even cover the hip. When I switch to a long coat, I won't feel different in terms of being a doctor or not, but I will feel like I look better."
Some residents have had stronger objections to wearing the short coats of medical students, rather than the long coats of a full-fledged doctor.
Dr. Debra Weinstein, who oversees graduate medical education at Mass. General, said she was surprised several years ago when a few medical students who applied to the hospital's residency programs wrote on a questionnaire that they objected to wearing short white coats. "Some people actually look forward to an expected change in coat length as a symbol of status or achievement and object if they don't get it," she said in an e-mail.
Similar comments from a resident in emergency medicine at Mass. General prompted that department to change its policy four years ago. Dr. Eric Nadel, program director for the emergency medicine residency at Mass. General and the Brigham, said he spoke to other attending physicians in the emergency rooms and decided there was no reason not to allow residents to wear long coats; many emergency medicine attending physicians at Mass. General break from the short-coat tradition themselves.
"I don't think I'm breaking any great laws of this institution, but I am breaking with tradition," he said. "But given the choice, most of my residents went to long coats."
Sandy Shea -- senior area director of the Committee of Interns and Residents, a union with a chapter at Boston Medical Center -- said she has received similar complaints. At Boston Medical Center, while most residents wear long coats, first-year surgical residents, called interns, wear short coats, she said.
"They tell me [their objections] in an embarrassed whisper," she said. "They would never bring it up to their attending."
Two years ago, one intern said he felt wearing a short coat was "infantilizing" and asked if there was anything the union could do about it. Shea said the union would not get involved in the issue unless there was a groundswell of protest.
Some attending physicians said they choose their coat length based on comfort, rather than the tradition at their particular hospital. Dr. Mitchell Rabkin, former president of Beth Israel Deaconess, has always worn a short coat at the hospital, even though long coats are traditional. "They drag on the floor when you're sitting down, they're hot, and they get in the way," he said. "It would be like trying to do your job with a dress that goes down to the floor."
Others said they like the tradition. "Medicine is a long process of training," said Dr. Akshay Desai, a cardiologist at the Brigham. The long coat "is a symbol for many of us of having completed our training and some sense of pride at being an attending. It's the signature of the attendings here."