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Dr. Bruce Peltier's 2011 White Coat Ceremony Speech

Bruce Peltier

"Identity"
White Coat Ceremony
Dr. Bruce Peltier
July 16, 2011

Thank you very much, Dean Ferrillo.

It is a distinct honor to speak at this very special event.

First of all, a warm welcome to parents, partners, alumni and other supporters, colleagues, and friends of the dental school. I’d like to begin by asking parents of dental and hygiene students to please stand and remain standing for a moment. Next I’d like to ask spouses, significant others, partners, other family members, and support teams to stand. Now I’d like to ask all faculty members who teach first year students to stand and be recognized. We want to thank you for all that you do, because we know that dental school is a team sport. You can’t do it alone.

Members of the DDS and IDS classes of 2013, and the Hygiene class of 2012, welcome to your White Coat Ceremony. You have good reason to feel proud and afraid, both at the same time. You all have worked so very hard to get here, and done so well! I know most of you a little bit, and some of you quite well, and I can assure our audience today that you are a very special group of young professionals. We've got a truly wonderful thing going on here at Pacific. We have a special and positive reputation, so we are able to attract the very best and nicest students in the country. They go on to perform well and treat patients well, which makes us better. As a result, our reputation is enhanced, so we can then attract more great students and faculty in the future. It's a very cool cycle, and we fully intend to keep it going.

There's a lot to feel good about, and there's also plenty to worry about, as well. This is indeed a great moment, for it marks the spot where dental students and hygiene students make the big leap from rubber faces and plastic teeth to real people, human tissue, and dentin. We like to mark this moment as powerfully as we can, because you students sitting here in front of us are about to begin a long career that must be built on a foundation of competence and trust. You Peter Parker fans out there could actually view this white coat as a radioactive spider bite. From now on there's great responsibility along with pretty great power.

The topic of my talk today is Identity. It could just as well be titled: "Who do you think you are?"

Research in western psychology informs us that the answer to that question — who you think you are — turns out to be of great importance, because who you think you are has a lot of influence on what you actually do and who you turn out to be.

David Leach, an influential medical educator explains it this way:

...medical professionalism depends heavily on the quality of a physician’s inner life. Transcendence of self-interest is not a technique—it is a way of being.

The concept of identity is pretty abstract, and I must admit that I have never completely grasped it myself. If you read the dental practice literature, which isn't really literature, you would see that practice consultants use the word identity to mean image.

They advise you to create a positive practice identity so that your patients will refer their friends.

But that's not how psychology views identity. We see it as a core quality, a mental model that powerfully influences how people behave. Psychology has created frameworks to try to understand and explain identity, and they typically describe development in terms of stages. When all goes well, one stage leads to another. When things don't go so well, you get stuck at one of the lower stages and you stop evolving.

You've heard of some of these models, which include Piaget's stages of cognitive development, where children evolve from concrete thinking to more abstract reasoning, and from an ego-centric or self-centered view to a way of thinking that takes in reality without significant distortion. In that model there's growth from a childish insistence that the world conform to you… toward a willingness to adjust your thinking to the world outside of self.

Then there's Maslow's hierarchy of needs, which asserts that humans begin life with a natural motivation to acquire food, warmth, and basic safety, then relationship needs, and if all goes well, eventually we are driven by a need for self-respect and a desire to reach one's highest potential to transcend narrow self-interest.

Erik Erickson proposed a series of eight stages of psychosocial development. Humans make their way up his hierarchy by resolving a challenge posed at each step. The early steps involve basic questions such as "Can I trust the world ? Can I take care of myself ? The later stages move on to social and abstract issues having to do with good and bad, and whether or not one can be productive. Erickson's highest stages ask the questions: "Have I produced something of real value?" and "Have I lived a full life?" These are large questions, to be sure!

Lawrence Kohlberg proposed stages of moral development. His early stages involve avoidance of punishment, obedience to rules and authority figures, and becoming a good boy or girl while still getting what you want. In his model a person evolves to what he calls "post-conventional morality" that attends to the social contract between individuals and their community along with abstract universal principles of right and wrong. We will study these principles, of justice, beneficence, autonomy, and reparation later this year in the ethics course, and I'll do my best to get you to memorize them!

There is an evolving body of professional literature about moral development in the professions of medicine, law, and dentistry. Research by my colleague Mickey Bebeau at the University of Minnesota implies that current dental students are (quote) "driven by more personal considerations" than previous groups, that you don't yet have a well-developed sense of professionalism, and that you are (quote) "reluctant to engage in self-regulation" (of colleagues). For the record, I don't get that impression about our students. You all actually seem quite eager to develop your professional identity in the most healthy way. We just have to help you do that.

The most important developmental model from this research indicates that dental students must be able to learn how to do four things: First, to spot ethical issues in day to day work; second, to be able to make the right judgment about what to do; third, to be willing to take action to make things right; and fourth, to continue this process in order to develop an ongoing tendency to do the right thing. This ongoing tendency is called "character."

So, what does all this have to do with dental school and that white coat on your lap? Well, as you may have noticed, all of those theories of psychological development assume that you will move from a primitive, selfish, concrete, rule following, simple-minded view to a more abstract, complex view that involves the social contract between doctors and patients and between you and your community. By draping you with this white coat, we are asking you to evolve your moral identity and to join a profession. By joining this profession you are being asked to adapt your moral views — and your view of yourself — to the norms of your professional group. By giving you this white coat we're actually trying to make it easier for you to join up, because there's a special challenge that faces most dentists in private practice. They tend to work alone, in isolation. There’s really no one watching over them, and when there's a difficult decision to be made, they often have only themselves to consult. That's what makes the matter of identity so important. If you see yourself as needy, or as a chronic victim, or simply a business owner, or even a hustler, you might not make decisions that are good for your patients or your community or your profession. Or even your own career, for that matter. When I evaluate dentists who are in trouble with the state board I often find that they were simply too isolated from their colleagues, their profession, and the standard of care. As you may know, the standard of care is a collective opinion. These wayward practitioners didn't view themselves as members of a profession, and they certainly did not feel that dentistry was a "calling." These are often people who got stuck at a lower stage of moral development and had little or no awareness that this had even happened until it was too late.

So that there can be no confusion about this white coat business and why you're getting it today, let me just come right out and tell you about the values and identity we encourage you to embrace. Dentistry is a profession, and the core idea of professionalism is fiduciary, that one person with expertise and special equipment performs an important task for someone else who cannot fully understand the situation or take care of it without help. Patients must be able to trust you to do the right thing for them, and to do it well. In order to be a professional you have to move up those hierarchies from selfishness to social good, and from rule-following to independent ethical behavior.

You have some important choices to make. We ask you to take a service orientation to your work and career, to look after your patients and to make their needs central to what you do. You don't necessarily have to put your patients' needs ahead of your interests, but you cannot put your interests ahead of theirs. When we say "service" we don't just mean that you should provide great service only to those who can pay for great service, either. We ask you to be generous so often that generosity becomes part of your character and your identity. We ask you to be kind to other people even on those occasions when you feel like strangling them. We ask you to engage in lifelong learning and improvement. We ask you to be assertive and to speak up when it's appropriate and especially when it's difficult. We ask you to tell the truth. We don't expect you to be perfect, but we do ask you to take the high road just as often as you possibly can.

Recent research on moral exemplars in dentistry reveals an interesting thing. When Bebeau and Rule interviewed dentists who were most highly respected in your field they discovered that these people did not feel that they had made any special sacrifices. They reported that they were just being themselves, just doing what more or less came naturally. They perceived no role strain. Their high level of professionalism was an authentic part of their identity. Their personal values and professional values were integrated.

Most of you are young, and in a perfect developmental stage to evolve. We chose you to a great extent because of your early moral promise, and we hope and expect you to grow. You've done extremely well so far. The white coat is a symbol of your potential for continuing moral development in your profession.

Even if you don't make it to the top stages of moral development, there are still two very practical reasons to take the high moral road and to continue to develop your character. The first reason is that you tend to feel better about yourself and about your life when you do so. The second is that — as the expression goes — it's a good practice builder.

To sum all this up, we give you these white coats to encourage you to adopt the identity of a doctor (or in the case of you hygienists, the identity of a health care professional). We often call you “doctor” in the clinic for the same reason. We want you to behave like a doctor, to think of yourself as a doctor, and to take on the identity of a doctor.

OK. The lecture's over, but here’s one last piece of advice:

Celebrate. You can start this in just a few minutes. Take time to appreciate what you have accomplished, and do this continuously throughout your career. Take care of yourself. You've come a long way, many of you through the first year of dental school at the Arthur A. Dugoni School of Dentistry, a world-class accomplishment. You’ve made it into the clinic and you’ve put yourself into a very good spot in life.

Congratulations.