First identified by Phillip Jackson [1] and other politically oriented curriculum scholars in the 1970s, the hidden curriculum is the "tacit ways in which knowledge and behavior get constructed, outside the usual course materials and formally scheduled lessons" [2]. Moreover, as Apple argues [3], the hidden curriculum reinforces the basic rules and codes of an institution and "posits a network of assumptions that, when internalized by students, establishes the boundaries of legitimacy."

Our teaching behaviors are some of the clearest signals that we send to students about what a professional is and does. The way we listen to and look at students, the way we talk to them, how accessible we are to them, what we expect of them and how we make our expectations known, how we respond to their accomplishments and failures, whether and how we share our own shortcomings and uncertainties with them-these signs are thick in the air at all levels of medical training, and students certainly breathe them in. In addition, many other institutional activities, organizations, and rituals in which medical students participate (such as student government or institutional rituals to denote professional passages) reinforce particular beliefs about and norms of professional behavior.

After witnessing a white coat ceremony from my window one day, I began to puzzle over the multiple and contradictory meanings of professional development embedded in this particular ritual. On the one hand, I marveled at the dignified, solemn ceremony that sought to join the materiality of a white coat with the virtues of altruism, accountability, excellence, duty, honor, respect for others, and compassion. It seemed to be a good fit, the linking of the clean, unsullied, white-as-snow coat with the lofty abstractions so central to our educational charge. Yet, on the other hand, I wondered how effectively the ceremony and the white coat itself addressed the less abstract, more difficult, more tangible habits that seem to be underdeveloped and underemphasized in professional development, such as taking personal responsibility for lifelong inquiry in the clinical, ethical, and policy domains of medicine; grappling with the ways in which race, sex, and social class influence medical care; working against unjust structures and policies in health care; and inviting the perspectives of those without a vested interest in medicine to participate in health care debates. How does the white coat ceremony speak to these issues?

Multiple Messages

In one of the most comprehensive studies of the white coat to date, Blumhagen [4] points out the importance of symbol and ritual in all cultures and describes how the white coat became the most recognizable, respected garb of physicians. First, he posits, the white coat was conceived with the concept of aseptic surgery, which originated in the United States about 1889; its purpose was to protect physician and patient from cross-contamination. Second, white coats gave physicians the appearance of scientists, with the "authority of science ... seen as validating the practice of medicine." Third, when care of the sick was moved from homes to hospitals, white coats also made the move. That is, "all people connected with the healing process, including patients and visitors, were to be dressed in white ... [and] white became associated with the institutions of healing." Add to all of this the western cultural meanings of whiteness-life, purity, innocence, superhuman power, goodness-and it is easy to see how the white coat became the favored garment for physicians.

It was no surprise, then, when the Arnold P. Gold Foundation selected the white coat to be a symbol of the profession and the center of a ritual-the white coat ceremony-intended to impress upon medical students the importance of compassion and humility in the midst of the high-tech, bottom-line-oriented practice of today's medicine [5]. This stated intention of the ceremony is unquestionably commendable, and most of us in medical education work toward this goal in our teaching and professional development efforts. Here, I call the white coat ceremony a ritual, which can be defined as a codification of an attitude [6] that is "stylized ... dramatically structured, authoritatively designated, and intrinsically valued" [7]. Who can argue against any curricular effort, including rituals and ceremonies, designed to move students toward "compassionate and humble" caregiving? What I question is whether the ceremony, or the white coat itself, is the best vehicle through which to encourage compassionate and humble caregiving. The white coat-a fixed article of clothing that medical students wear to symbolize altruistic virtues-lends itself to multiple, conflicting interpretations in addition to the positive ones cited above. It can symbolize caregiving hierarchies and spheres of practice, the social and economic privilege of physicians, and medicine's well-established practices (not unlike those of the law or the priesthood) in determining membership in the profession.

In his comprehensive study [8], Joseph points out the critical importance of the patient's perspective on the white coat, which is a type of "occupational clothing" or quasi-uniform. Patients are vital to the self-image of the white coat's wearer, and patients' reactions to physicians are based on both linguistic cues and nonlinguistic symbols, including the white coat. Physicians in training acquire their self-images by "testing" their emerging roles on patients; watching patients' responses; and ultimately "accepting" themselves as physicians, largely because patients do.

Some might argue that symbolic garments are found in many professions and that to single out the garments of medicine as having elitist or exclusionary dimensions (however unintentional they may be) is unfair. I respond that the significance of the white coat differs vastly from the significance of the occupational clothing of other professions. This is because of differences inherent in the natures of the professions in question and because of the asymmetry inherent in the physician-patient relationship, an asymmetry that derives from educational, technical, social, and economic differences between physicians and patients. The nurse-patient relationship is, in theory and in practice, not the same as the physician-patient relationship. The judge-plaintiff and clergy-parishioner relationships are also different; both are based on a whole other set of material issues with different goals and implications for the relationship.

One important issue in professional development, then, is that students must recognize how differently patients and nonphysician caregivers "read" their white coats and what these readings mean to the kind of care that they give, or think they give. Of course, many patients like the white coat: It symbolizes that the person caring for them is well trained to do so [9]. It also makes it socially acceptable for a physician to address private physical and emotional matters, things that would be taboo in a nonmedical setting [4, 5]. Moreover, as Kaiser points out [10], persons who wear occupational clothing or uniforms are

"... assigned a particular role set. Uniforms not only allow outsiders to identify individuals as members of the organization, but also enables insiders to interpret their rank, duties, and privileges ... . A basic relation of power, or who controls whom, is conveyed through organizational use of uniforms."

How, then, are medical students to reach a broader understanding of the sometimes conflicting meanings of the white coat? How are they to realize that the coat is, aside from the assurance it may give patients, only an article of clothing, and that the body under the coat is as complicated, variable, and imperfect as the bodies of the patients they touch? To link a white coat to a mythologic, Welbyized image of a physician who is always decisive, who is "immune" to variations in economic and social status, race, ethnicity, national origins, and sexual desire; to differences in body type, size, appearance, and hygiene; and to variations in family structure, religion, occupation, political beliefs, and moral life, sets students up not just for failure but also for guilt, cynicism, and denial when the ideal fails to materialize. The one-time white coat ceremony may not be the best medium through which to confront and work against the biases and beliefs that get in the way of a fuller realization of compassion and humility.

As Sherwin points out [11], persons-and this includes physicians in training-do not

"present themselves as fully grown and complete in the world, ready to perform actions and form social contracts as autonomous, self-sufficient beings. Rather ... [persons are] the product of the physical and emotional labor of other persons who socialize them."

Who socializes medical students? Cultural conceptions of "the doctor" do some of the work before students even arrive at medical school. Once they are there, it is primarily the faculty who teach them, write the syllabi, and sit on the committees that author and enact the formal policies of the institution, including the discourse on professional development. Medical faculty are a remarkably homogeneous group, and their homogeneity can distort their perceptions of those outside the circle. Sherwin continues [11],

"Homogeneity among participants in debates [and policy formation] has consequences in any field. One important effect is that it allows most practitioners to remain oblivious to the significance of their own location and perspective ... . As in other disciplines that are dominated by a well-educated, white, male elite, the fact that most of their colleagues share the same perspective makes it easy ... to lapse into false generalizations from their own experience."

Thus, the perspectives of other health care providers, not to mention patients, are not included in formulations of policy about what the "professionally developed" physician should be. These omissions are part of the hidden curriculum of professional development, just as the white coat sets the physician apart from nonphysician caregivers and from patients. Moreover, because few persons outside of medicine are involved in the conceptualization of physicians' professional development, we do not even think about our self-invested stance when no one is there to counter it.

Mahowald [12] writes of such medical myopia, arguing that a corrective is needed to the nearsighted, often exclusionary nature of curricular decision making. Labeling this myopia "unselfconsciousness," she posits that physicians often lack a sense of their limitations. They believe that they have a "point of viewlessness" gained through their training or position, and this belief is reinforced by titles, traditions, and cultural attitudes.

Wearing the white coat, the occupational clothing of a prestigious group with substantial power over human lives, may actually promote unselfconsciousness rather than remind physicians to show compassion and humility. Doctors may become the coat, sometimes keenly aware of and sometimes unconscious of the way persons respond to them-with deference, respect, shyness, self-consciousness, or even silence. A medical student, upon donning the occupational clothing of her profession, quickly recognizes that it establishes her "right to a given status without her need to prove herself" [8]. With such a status conferred by patients, medical students and, later, physicians may lose sight of the importance of critical self-reflection. Indeed, students may actually become less aware of their limitations as they are socialized by their medical training, the reactions of patients and other nonphysicians to them, and the media and other cultural forces.

Creating New Rituals

Aren't there better, more systematic ways to symbolize professional development in all of its abstractions, propensities, affinities, values, and concrete behaviors, ways that can be woven throughout the curriculum? What ceremonies or rituals might be invented to honor and renew the goals of professional development, particularly compassion and humility? I offer some ideas. The first has to do with who participates in deciding what professional development means; the second has to do with the ceremonies, rituals, and other routinized experiences used to encourage this development.

First, in deciding what should constitute professional development, physicians and medical educators could be joined by representatives of community agencies and other entities that minister to a wide range of society's needs, such as shelters, free clinics, reproductive services, food banks, drug and alcohol intervention programs, and counseling agencies; how do these agencies define good doctoring? What about public health practitioners, social workers, nurses, nurse educators, and allied health professionals? Advocates and activists from interest groups working with issues of race and ethnicity, poverty, illiteracy, and sex? I have to believe that if all of these groups worked together, a different and more intensive discussion of health care-and, ultimately, doctoring-would take place. Indeed, according to Sherwin [11], "there might be greater interest in really grappling with prominent health concerns of the underclass. Those concerns would include poor nutrition, inadequate shelter, unsafe work and living conditions, abuse, addictions, and lack of prenatal services."

Second, professional development might be ritualized very differently, this time with the idea that if a ritual is to be alive and have meaning, it must be intrinsically valued by participants and must be regularly repeated, dramatically structured, and authoritatively sanctioned [7]. This could occur in some kind of predictable, systematic, routinized way in the formal curriculum, where medical students may find themselves in community-based sites where the perspectives and the lived experiences of a wide range of people-including the least privileged-can be heard. A regularly scheduled day or half-day per month in free clinics, domestic violence shelters, adult day care centers, rape crisis centers, community drug boards, or hospice settings over a 4-year period has far more potential than a one-time white coat ceremony to encourage the socially conscious, compassionate caregiving that is at the heart of professional development. "First Fridays," for example, could become the symbol of professional development, a ritualized demonstration of humane medicine, sanctioned by the educators who seek to promote such traits, modeled by caregivers on location, and serving communities whose needs and opinions are often overlooked by the dominant (including the medical) perspectives of our culture. Or perhaps more of us could follow the lead of Wright State University School of Medicine, where 60% of students' clinical training takes place in outpatient settings, such as community health centers, schools, and geriatric centers [13].

Will this curricular activity assist students in their professional development more significantly than white coat ceremonies do? I believe that it will. Yet I acknowledge that the issue can be framed in another way, not as either a white coat ceremony or other rituals. What may be most critical is the realization that white coat ceremonies probably don't foster much of anything if they are not embedded in institutions that live and breathe the qualities the ceremony espouses. Similarly, in institutions where white coat ceremonies exist and are valued by students, the most critical question may be, How do we keep the qualities honored by the white coat ceremony-compassion and humility-alive and vigorous throughout the curriculum, valued in every course, embodied by every faculty, and recognized and honored in every student who exhibits them?