| The Fashion Issue | Winter 2007 |
The Proctologist Wears Prada Everything I know about fashion I learned in hospitals. You might suspect that’s a bad sign—and you’d be right. After all, would you trust On the first day of medical school, the White Coat Ceremony begins the training students will need to tolerate medicine’s frumpiness. Further challenges follow soon after. For me, the second lesson came when a professor mentioned the lipstick sign of returning health. As soon as a female patient begins wearing lipstick again, he said, it shows she is well enough to care about her appearance. I wanted to look healthy, but in the man-sized jacket the hospital had given me, lipstick looked like drag. Naturally I chose looking like a doctor rather than looking healthy, and I avoided lipstick from then on. Clothes Ranks By the end of the first week, all students know that coat reveals rank: short white coat means resident; clean short white coat means medical student. Long white coat tends to be a diagnostic sign for attending. Bespoke white coats are pathognomonic for surgeons. Stiff blue suit coat: residency applicant. Those blue interview suits—why do people applying to be a doctor dress like drug reps? I used to ask all the applicants that question, until my department chief made me stop. Still, it’s sometimes better that an applicant’s attire is openly discussed. A few years ago I interviewed a nervous young man in a blue suit and a Brigham and Women’s tie. A refreshing variation on the usual red interview tie, I thought, except that the interview was at Massachusetts General Hospital. Applicants generally relax as the interview progresses, but this young man sounded more and more strangled. My chief is right, I thought sadly, I do ask rude questions. Finally, the applicant stopped speaking altogether. Then he blurted, “The reason I’m wearing a Brigham tie is that when I interviewed there this morning I spilled coffee all over my paisley tie and this is the only kind their gift shop sold!” With that problem off his chest, the interview went more smoothly. Ties more often signal subspecialty than physician location: the cartoon ties of pediatricians, the Hermès ties of dermatologists, or the bow ties of gerontologists. Are they growing to dress like their patients, just as researchers start to look like their experimental animals? For the gerontologists, there is a more fundamental safety issue. Even young ones wear bow ties because of the tie sign of dementia—the patient’s dementia, not their own progeria. In the tie sign, elderly patients grab the doctor’s tie because of a disinhibited grasp reflex. Hospital security guards push even further into the tie fashion frontier with their clip-on ties, which act as quick-release straps when dealing with grabby psychotics. Patient fashion can be diagnostic as well. Those whose hats are lined with tinfoil need a different ICD-9 code than those who wear gold lamé before the cocktail hour. While latex gloves on an outpatient suggest mysophobia, cotton ones suggest dermatitis. A single cotton glove on a hand tucked under an arm, though, more often signals reflex sympathetic dystrophy. To sharpen their diagnostic skills further, eager medical students practice the elevator training drill known as Match the Patient to the Clinic. Patients in dark glasses get off at the cornea clinic. Those in bike helmets head for the seizure clinic. People dressed like construction workers go for the back pain clinic. Women with Macy’s bags of spine films: back pain clinic. Men in corsets: back pain clinic. Frocks for Docs My fashion education on the wards was often explicit. During one rotation, the other medical student was the sole man. He was pre-ortho, as his crew cut and XL white coat made clear. One day he plaintively asked Patty Gibbons, the junior resident leading the team, “How come you gals don’t talk about sports, like on my last rotation? Now it’s all about clothes.” She recognized the teachable moment. “You don’t find fashion interesting?” “Oh, I bet it’s fascinating. It’s just not something I know anything about.” “But that’s treatable,” Patty said. “We’ll just add fashion training to rounds. A quiz. Med students love multiple choice. Let’s start now. Are my shoes slingbacks or mules?” Each day we covered a new anatomical area. “Is this skirt tea length or knee length?” “Camisole or chemise?” The medical student was smart. By the end of his rotation he performed well above chance on the quizzes. Several years later he ran into Patty. He had matched in orthopedics, and his coat size was now XXL. “Patty,” he said, “I’m so grateful for everything I learned on your medicine team!” “Does that mean you place internal jugular lines, like we do in medicine, rather than those dangerous subclavian lines, like surgeons?” “Ah…sure. But also, when I go on a date, I can say things like, ‘Nice slingbacks.’ And my date always says, ‘You are so sensitive!’ ” Dressing for Success Besides cardiac code calls, hospitals have fashion code calls. And doctors must call those codes not just on patients, but on each other: for the silk ascots on those courting the carriage trade, for the dreary buns, and for other cranial pathologies such as the infinite comb-over—a single mutant hair that coils around and around a bald spot. One clothing historian has postulated that doctors originally adopted the white coat to prevent codes from being called on the pilled, part-polyester gabardine underneath. One institution that has been relatively free of these morbidities is UCLA Medical Center. This first struck me when I gave a lecture in its psychiatry department a few years ago. The beards were neatly trimmed, there were no novelty ties with brains or Freud on them, and several doctors seemed to be engaging in what ethologists call deceptive signaling: Not only were they wearing white coats despite being psychiatrists, but, even more shocking, their white coats fit. On a recent trip to Los Angeles, I learned why. While I was on the set of a medical drama there, the costume designer approached me to ask, “Do all New England doctors dress like you? It’s so different from the doctors here.” I tried to dodge that question with my own. “Where do you get those white coats that fit?” “At Scrubs Unlimited,” she said. “They do all the Industry. They’re in Westwood, right next to UCLA Medical Center.” The Plight of Fashion One of the more emotionally fraught medical fashion cases I’ve seen was that of a middle-aged man whose dopaminergic treatment for Parkinson’s disease made him start cross-dressing openly. This was a variant of a dopamine side effect called punding, an intense and idiosyncratic goal-directed behavior. Mirapex-induced gambling is the example that has received the most press coverage, but I have patients whose drive is to bake bread, rebuild cars, or compose music. I had heard of this patient for several years before inheriting him from a colleague, and I’m ashamed now that I looked forward to meeting him simply because his symptom was so piquant. By the time he became my patient, though, he was so physically debilitated that his cross-dressing had crossed the fine line from comic to tragic. He spent his considerable willpower and last shred of energy on dressing to the nines, but his face and body twisted painfully, and his chiffon dress was drool-stained. My medical training had not taken completely—I remember noticing that the chiffon was white, though Labor Day had passed. His job as an attorney had helped him become a powerful advocate for the rights of transgendered people. His mission continued even after his death, as his obituaries carried sympathetic coverage of his struggles. While he was still alive, my patient’s wife had responded calmly to his sartorial struggles, without pretending his incarnations weren’t painful for her. After his death, she was thoughtful about why she had helped him enact the person he had become. She shared with me essays he had written, photographs of the mirrored sculptures he had started making (his punding did not detract from their grace), and testimonials from friends about the ways he had turned his symptoms into strengths. As a person grappling with illness, my patient had written a moving essay in the Boston Globe on what it felt like to stop taking levodopa at nine in the evening and then lie completely frozen until his next dose at six the following morning. He argued that the euphoria of feeling his body come back to life was worth the living death of the night before. The joy that came through even the frail medium of that newspaper article made me better understand his wife’s and his friends’ testimonials. His wife told me about packing up his clothes after his death. “People warn you it will be difficult,” she said. “A part of you still hopes that maybe he’ll return somehow, and he’ll need that shirt. I gave most of the dresses away, and then I hung his old clothes, his suits, back up in his closet. They’re the only remnants of his first self.” When I talked to her a few years later, she tweaked that story gently, adding, “Sometimes I use his old crêpe de chine gowns to help me sleep. They’re so wonderfully soft. I don’t want to forget his second self either. The love of fabrics he developed; that’s one of the things I learned from him.” My patient’s drives were dopamine fluctuations, nothing more—but they were also much more. Part of me would rather avoid the fact that my desire not to wear lipstick came from the same neural circuits that produced his desire to wear it. The rest of me knows that in tweed and in chiffon, through will and biochemistry, he did something remarkable with his life. Alice Flaherty ’94, a neurologist at Massachusetts General Hospital, recently turned in her hospital-issue white coat for one from Scrubs Unlimited that fits. Photo: Stephen Webster |
clothing advice given by people who consistently break the rule against wearing white after Labor Day? 
|