What should we think of white coat ceremonies and first Fridays? In answering that question, we need to consider not just the formal curriculum and the hidden curriculum but also the informal curriculum. As Wear points out, white coat ceremonies overtly affirm humanistic values in the formal curriculum; in the hidden curriculum, which exists behind our formal attestations, white coats also symbolize power and authority. By the informal curriculum, I refer not to hidden symbols but to the overt influence of the hallway conversations, dining room and dormitory talk, comments on rounds, and ways of treating persons on the wards to which students are exposed. White coat ceremonies seem to try to inoculate students against the unsavory effects of the informal curriculum: the lack of compassion, the blurring of ethical boundaries, the treating of patients like objects, and other moral quagmires that probably affect the education of medical students at least as powerfully as the hidden curriculum of symbols does. My colleagues and I, for example, after reading third-year medical students' stories of their experiences on clinical clerkships, concluded that adapting to the medical culture was extremely problematic for these students [2]. Others have reported that medical students feel that their core ethical values are eroded during their clinical years [3]. Others have even reported on the abuse of medical students [4].

In analyzing the informal curriculum, Hundert and colleagues [5] concluded that many students suppress humanistic values simply in order to get on with their work. These authors also believe that the culture of the medical wards is antithetical to the reflection and self-discovery needed for professional development. In fact, the acculturation of physicians involves deep-seated issues. Konner, in Becoming a Doctor [6], concluded from the participant-observer point of view of an anthropologist that stress and fatigue may actually enable young physicians to bypass "existential moralizing and grapple with the grotesque pragmatic reality" of caring for the sick. He believes that physicians are allowed to do what they do "because of the rigors of the training," that the physician pays for his or her power with suffering.

Given the depth of the issues involved, I suspect that both white coat ceremonies and first Fridays will prove inadequate to support the professional, moral, and ethical development of students. The white coat ceremony seems important, but it is only one part of what is needed. Wear's proposal that students visit drug rehabilitation clinics, rape crisis centers, and other community agencies is laudable, but it could readily result in cynicism unless its implementation is carefully designed and supported by adequate structure and mentoring. In an alternative approach that may have promise, my colleagues and I implemented a required curriculum of weekly small-group sessions in which students reflected on their ethical and humanistic values throughout the third-year clerkships [7]. Despite the above concerns about the depth and influence of the informal curriculum and the complexity of the transformation from layperson to physician, I believe that such opportunities for deep, honest reflection can and do keep students' moral values alive during their clerkships [7-9]. All of the above and more is needed to elevate professional development to its proper place in medical education. And, although students do need to know more about the community, medicine needs to clean up its own backyard: The main educational battles over humanism will occur in the teaching hospitals and clinics, where many disadvantaged persons receive their medical care. But the informal curriculum, a dogged foe, changes and adapts to each new condition. Ultimately, its less desirable effects are likely to give way only when our efforts to counteract it are vigorous enough and when sufficient numbers of positive role models are available among housestaff and faculty.

We should have more white coat ceremonies. The ceremonies should emphasize that physicians need to tread very gently with their power. Those who have been very sick-and I count myself among these-know firsthand how much power physicians wield. It has been my experience that most mature physicians are aware of this and treat their patients with great gentleness and consideration. But to ease the transition from student-doctor to fully mature physician, we need to learn a great deal more about how to strengthen humanism within the formal curriculum. Only then will we begin to overcome the hidden and informal forces that insidiously, negatively influence medical education.