A Country Doctor's NotebookBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39136.684144.59 (Published 01 March 2007) Cite this as: BMJ 2007;334:479
- Chris Bird, F2 doctor in obstetrics and gynaecology, John Radcliffe Hospital, Oxford
In 1916 Mikhail Bulgakov, 24 years old and fresh from medical school in Kiev, was posted to a snowbound rural clinic in northwestern Russia, “thirty-two miles from the nearest electric light,” to fill a gap left by doctors serving on the eastern front. In his semi-fictionalised account, A Country Doctor's Notebook, the young medic spends the journey to the remote hospital on rutted tracks, worrying about how he will cope with tracheotomies and obstructed labour (he has seen only two normal deliveries at medical school), fretting over his youthful appearance, and urging himself to walk, not run.
He doesn't have to wait long before a cart rumbles into the hospital yard carrying a young woman with a leg smashed in a flax brake, her pulse barely palpable. “‘Die. Die quickly,' I said to myself. ‘Die. Otherwise what am I to do with you?'” However, he horrifies himself by ordering the “feldsher,” the Russian equivalent of a physician's assistant, to prepare the theatre for an amputation. His own adrenaline as potent as the camphor injections given to revive the patient, he saves her by removing the leg.
Later he is presented with a fetus with a transverse lie and has to examine the woman in front of the hospital's veteran midwife: “The fact was that once the experienced Anna Nikolaevna had told me what was wrong, this examination was quite pointless.” The midwife breaks protocol, advising a “podalic version.” The doctor gravely concurs, announces that he's off for a cigarette, and runs to look up “podalic version” in his textbook of operative obstetrics. As they scrub in, Anna Nikolaevna recounts how his predecessor performed the procedure. “I listened avidly to her, trying not to miss a single word. Those ten minutes told me more than everything I had read on obstetrics for my qualifying exams, in which I had actually passed the obstetrics paper ‘with distinction.'”
Such an internship, including an attack by wolves while on his way to a home visit in the middle of a blizzard, is no longer the norm for house officers (although it remains so for many doctors in the developing world). But Bulgakov's struggle with the dark Russian winter swirling outside his window symbolises the lack of experience, loneliness, and the worry of breaking the Hippocratic oath that gnaws at the sleep of junior doctors everywhere.
Shattered by morphine addiction, typhus, and his forced conscription during the brutal Russian civil war, Bulgakov abandoned medicine to write, including the novel The Master and Margarita. The attentions of the Soviet censors, Stalin's secret police, and renal disease pushed Bulgakov into an early grave (his brother Nikolai escaped Russia to become a respected cardiologist in Paris). He had his doubts about the medical profession—“I won't call doctors murderers, that would be too harsh, but I will call them casual untalented hacks”—but medicine was for him a light in the dark days of Soviet repression. “Each person ought to be a doctor,” Bulgakov wrote, “in the sense of disarming all the invisible enemies threatening life.”
A Country Doctor's Notebook
By Mikhail Bulgakov
First published 1925-7