khakis and button-down

Today at our hospital's ACLS training for incoming interns, the Harvard boys were clustering together a little more than we should have been. (Knowing myself and the others, the clustering was more social anxiety than it was snobbery, but of course that's a fine line.) More remarkably, of seven Harvard Medical chaps who were there, all seven were in some variation of khakis and a button-down, no tie. I think five had blue shirts on, and two had white shirts. (Or was it four and three?) One of our group of Harvard boys was dressed slightly more casually yesterday, but he fell into line today.

No one else among the incoming interns from other schools was dressed exactly this way. Most were a bit more casual. It was a training, and therefore there was no clear dress code. A few were as formal as we were but in different ways: with different kinds of colors, fabrics, and so on.

I didn't dress this way before. I lived in San Francisco and wore jeans to work; when I bleached my hair my workplace credibility as a community organizer went up, not down. My lab boss in Bethesda wore all black clothes (except she wore bright yellow clogs) because she didn't want to be bothered with the problems of matching colors; no dress code there either.

Harvard changed me. Harvard somehow made me think that I should dress this way. And I think we tuned ourselves to each other: we looked more alike the second day of training than we did the first. But clearly, long before this training, without anyone explaining it or demanding it of us, we all became the guys who wear the khakis and the open-collar blue shirts.

"It's what I'd wear if I was coming over here to meet with my research advisor," said A, one of my co-terns. I said, "Of course; me too." On some level, we both felt--well, what else would you wear? In fact, I had semi-consciously run through the differential on both mornings before the training days, looking in my drawers and my closet. I thought about a dark plain polo shirt but it seemed some combination of too casual and too golf-y. Jeans were out of the question. Definitely not a t-shirt. Not even an untucked short-sleeved button-down. I don't own any brightly-colored button-down shirts; if I did I wouldn't have chosen them. Yet other men there made all of these fashion choices, and others like them.

When I told her about all this, Ms. Hemodynamics said, "Well, sure. That's part of why they were recruiting you guys."

"But I find this distressing," I said. "That somehow the institution has taken my aesthetics and eccentricities and ironed them out of me."

She understood this; but she thought my clothes were still the right choice. And of course, my program had been recruiting her too.

White coats at protests? Maybe not.

Photo: Treatment Action Campaign and Student Global AIDS Campaign protesters at last year's International AIDS Conference, part of a coalition opposing Abbott Laboratories' approach to access to AIDS drugs.

I'm going to be taking part in a global day of action to condemn Abbott Laboratories for their attempt to block compulsory licensing of one of their AIDS drugs, known in the United States as Kaletra. This is an important medicine for people with AIDS, and Thailand wants to produce generic versions of it for impoverished people living with HIV and AIDS, who could not otherwise afford it.

The Bangkok Post has an editorial which lays out the legal issue from a Thai point of view. This one is pretty stark: Abbott is deliberately trying to roll back agreements about international trade rules, because the company doesn't like them.

There's more to say about Abbott, but I'll save that for now. In the meantime, I am now wrestling with a less important problem familiar to all 4 or 5 regular Hemodynamics readers, and a problem that afflicts all casual activists who only attend protests now and then: what to wear.

On its face, this is a silly thing to spend much time worrying over. But protests in the television age, and even more so in the digital image age, require careful attention to symbolism. And it turns out that as a future doctor I've got a lot of symbolism to think carefully about.

Medical students have often worn white coats to protests, as have doctors. This is a way of bringing professional credibility as a form of solidarity. But I've never done this, and though I thought about it earlier this evening, I don't think I will this time either.

This particular issue is fairly clear: when people don't get medicines to treat HIV, they often die of AIDS. Incredibly enough, and despite everything bad you can say about an organization like the World Trade Organization, nations around the world have agreed on ways that countries can make sure people get medicines. If you want to reap the benefits of global capitalism you should at least play by its very limited rules.

This message does not require a white coat for its credibility.

To say that you should listen to my views about intellectual property policy because I'm going to be a doctor would be absurd. After all, so many other doctors have been so egregiously wrong about this kind of issue that I would hate to encourage people to listen to doctors about patent policy. As far as the embroidery on my white coat, it says "Harvard Medical School" and it doesn't say my name. And I don't believe there's anything about my Harvard Medical School education that makes me any more equipped than any other reasonably well-informed person to express my opinion about Abbott's approach to intellectual property. All I know now that I didn't know before is the details of how people die from lack of medicines, and what happens to their various organ systems as they get more ill.

You could argue that wearing the white coat is a kind of threat to Abbott, along the lines of the anti-Abbott coalition's suggestions for doctors that they prescribe equivalent generics instead of Abbott products, refuse to talk to Abbott drug reps, and refuse to accept gifts from Abbott reps. But for me, this would not be sending the right message: whether or not Abbott cares about Thai people living with HIV and AIDS, I will prescribe generics when I can, I won't talk to drug reps, and I won't accept gifts. If I was the kind of doctor who was actually thoughtlessly prescribing unneeded overpriced brand name drugs and getting chummy with drug reps, I probably wouldn't be going to a protest at Abbott headquarters anyway.

Another entirely opposite direction would be the Treatment Action Campaign's "HIV Positive" t-shirt. But I've always felt that this shirt has a different meaning in the United States than it does in South Africa, and it definitely means something different when worn by groups of people which do not include many people living with HIV. In the US, the meaning of this shirt can be helpful but it can also be presumptuous; tomorrow, at least, I'm not taking this approach.

The only visual signal I might feel comfortable displaying is letting people know that I am a health worker--someone who makes it their life's work to care about the well-being of people who are sick. I'm uncertain about the political value of that gesture, but I think that at least it is a visual reminder that the protest is an issue of health, and survival, and not just an issue of market rules.

In other words, I've reduced my protest wardrobe to two alternatives: I can either dress as just me, a concerned citizen--or I can dress as a health worker. Considering the health worker option, I realized once again that if I take this route, I would not wear the clothes of the profession (the white coat), but of the hospital and all who work on its clinical floors: I would wear scrubs.

Fleeced.

After many loud denials and proclamations against it, I have reversed my position: I have purchased a class fleece.

But before we come to why I finally committed this dastardly act, it's worth explaining the broader phenomenon of medical fleece. I'm not sure exactly how it happened. But I'm pretty sure it started happening about two years ago: every health-related group started getting fleece jackets and vests with their logos and team names embroidered on the left chest.

This is not unique to healthcare. In fact, I think the first local fleece explosion came from the Harvard Business School students. They've been walking around town for the last several years with HBS fleeces, each with their section name on them, full of mysterious significance. The HBS logo, initials and class year are accompanied by a big proclamation of "Section A" or "Section C", and so on, generic and externally meaningless, only serving to alert fellow HBS students to the room of people to whom the fleece-wearer was randomly assigned. In fact, it is their sheer meaninglessness which is their meaning. The fleece above all is an expression of group membership, and what is more in-group than a piece of arbitrary jargon? I'm sure that computer companies and consulting firms have been handing out team fleeces for even longer, and for the same reason. (I feel like I've seen fleeces that say stuff like "HDC Implementation Task Team" or similarly obscure nonsense, but who can remember that kind of thing?)

Last year or the year before, I'm not sure which, doctors-in-training in the Boston area joined the fleece craze. They started getting fleeces with their hospital logos and the name of their department: "Internal Medicine" or "Surgery." Soon after, nurses and attending physicians started getting more specific kinds of team fleeces: "Obstetrics L &D"; "MICU"; "Emergency". (This has the effect of one-upping the housestaff fleece. Because it says you work on a particular floor, doing a particular job, it also says that you are not a trainee.) These fleeces began replacing the white coat as a way to walk around the hospital and look like you belong there. For medical residents, they also were a proclamation of your team. If you were a meddie, you walked about in your team fleece that said "medicine" loud and proud.

Other hospital fashion changes started earlier, and I think they're related. Housestaff long ago started wearing scrubs around the hospital, even in situations where they clearly don't really need them, as did many other kind of healthcare workers. Scrubs have become a hospital worker uniform. Doctors and radiology techs can all wear the same pajamas.

It's not like hospitals have ditched hierarchy. So we should probably wonder why scrubs appeal to so many different healthcare workers regardless of status.

The first reason is utilitarian. The hospital gives them to you and then takes them back and washes them; you don't have to iron anything; and they're comfy.

But scrubs also signify more than sheer laziness. For those who wear them when they don't have to, scrubs signify a kind of industrial worker of healthcare, too busy saving lives to put on pressed shirts and ties. There's a kind of reverse glamour to scrubs. Scrubs originally come from the operating room, and they're designed for people who are ready at any moment to get themselves splattered with blood. Now people in the hospital who have nothing to do with surgery or fluid-splattering of any kind wear scrubs, as if to signify that they are part of the larger project of fluids splattering about, even if they personally are not going to get splattered.

I think scrubs and fleeces are part of the same set of social changes. Obviously no one intends to get their $100 Patagonia logo-embroidered fleece jacket splattered with body fluids. And yet it's common for fleece-wearers to be wearing scrubs underneath the fleece, walking down the empty lonely corridors in what is an outfit of pajamas, a jacket made out of material that feels like an infant's blanket, and round shoes without laces. In other words, medical fashion and toddler fashion have nearly met up. This is about comfy coziness, and definitely not about fighting through spurting arteries.

Housestaff and other healthcare workers sometimes wear their fleeces over other outfits, too. It's common to see medical housestaff wearing clogs, khakis, a shirt and tie, and their fleece, with their ID flapping around on a lanyard over the fleece. This is where the social functions of the scrubs and the fleece are headed in the same non-toddler direction. These are elements of a postindustrial factory-floor look. The fleece takes the role of the corporate identity (the hospital and department, without specifying the profession), rather than the white coat taking the role of the professional identity (the doctor, from a particular hospital).

As long as they avoid those nutty teddy-bear print scrubs that so many nurses have unfortunately become afflicted with (talk about toddler fashion!), the outfits of nurses and doctors start looking more and more alike: scrubs, fleeces, clogs. (Folks like radiology techs, respiratory therapists, and physical therapists can all potentially get in on the act too, although they've been slower to get the whole outfit together.) The scrubs and the fleece become about team membership, just like a white coat is about team membership. But it's in the hospital team sense rather than the professional team sense. I'm not sure that this provides any less distance from patients, but it's a different kind of distance. It says, "We're part of the hospital" rather than "I am a doctor."

So, why am I getting a medical school class fleece? Partly because my partner J says, "I got some of that college stuff when I graduated and later I was grateful"; partly because I want another warm zip-up sweatery thing for spring and fall. And then there's the problem that I'm just dying for a team fleece, even as I know it's a little ridiculous. I'm secretly as eager to be part of the world of medical fleeces as I once was to be a paramedic and wear a special paramedic uniform and drive around in a red truck with sirens.

At first, I had proclaimed against the fleece because it had our school's coat of arms. Also, it was crazy expensive. But proceeds beyond the retail price of an unadorned fleece jacket go to some kind of class party, which is fine. And at the end of the day, I have to admit that I'm actually proud to be graduating from medical school. I went from not remembering how to multiply fractions when I decided I was going to try to take chemistry, to getting a medical degree from a coat-of-arms kind of place. If the medical school fleece is some kind of aggressive status symbol, I at least feel as if I more or less earned it.

And what I earned is under the coat of arms: "MD 2007". The business school students can have their "Section A" and wear their fleeces like they're headed out to the team-building ropes course, I say smugly to myself; my fleece says "MD 2007" and I'm ready for the MICU. Their fleeces are practice for the consulting firms and investment banks which will give them their next fleeces; our fleeces are pre-hospital fleeces.

I'll get the actual hospital fleece soon enough. But for now, the medical school class fleece is a kind of hospital fashion/professional fashion hybrid. It's a white coat statement with a hospital floor sentiment. And right now, that's exactly who I am. That's the right fleece for me.