Richard Smith: Junior doctors in Russia 1917; Edinburgh 1977; and now—all the same?

In A Country Doctor’s Notebook Mikhail Bulgakov describes his experiences of being a newly graduated doctor sent alone in 1917 to run a hospital in rural Russia some 24 hours by sleigh from a bigger hospital. In most of the stories blizzards and wolves howl, and the peasants he is treating live in a pre-Enlightenment world unchanged for 500 years. What, you might think, could be more different from the experiences of a junior doctor in Edinburgh and New Zealand in 1976-78, but as I read the stories they reminded me sharply of my own experiences as a junior doctor. And I wondered how similar might be the experiences of my daughter who (assuming she passes her exams) will start as a junior doctor in August 2020.

On his first night in the hospital Bulgakov is terrified:

“I dreamed of the nearest town, thirty-two miles away. I longed to leave my country clinic and go there. They had electricity, and there were four doctors whom I could consult. At all events it would be less frightening than this place. But there was no chance of running away, and at times I realised that it would be cowardly. It was for precisely this, after all, that I had been studying medicine. 

“Yes, but suppose they bring me a woman in labour and there are complications? Or, say, a patient with a strangulated hernia? What shall I do then? Kindly tell me that. Forty-eight days ago I qualified “with distinction”; but distinction is one thing and hernia is another. Once I watched a professor operating on a strangulated hernia. He did it, while I sat in the amphitheatre. And I only just managed to survive …” 

More than once I broke out in a cold sweat down my spine at the thought of hernia. Every evening, as I drank my tea, I would sit in the same attitude: by my left hand lay all the manuals on obstetrical surgery, on top of them the small edition of Döderlein. To my right were ten different illustrated volumes on operative surgery. I groaned, smoked and drank cold tea without milk.”

In fact they brought him a young woman who had almost amputated her leg in an accident. She seemed to be almost dead, and Bulgakov’s assistants advised him just to let her die. But instead he injected her with camphor and proceeded to operate. He’d never done such an operation. She didn’t need an anaesthetic as she was so close to death. Remarkably the operation was a success, and the woman lived. This cemented his reputation and meant many more patients came to see him.

I emphasised with the terror, lying unable to sleep in the doctor’s quarters praying that nobody would ring. I remember too when I went to be a Casualty Officer in New Zealand, getting up at 4am in the morning, smoking (which I didn’t often do), and reading The Casualty Officer’s Handbook before going on duty at 8am. Like Bulgakov I felt woefully unprepared.

Later in the book Bulgakov describes being called to see a pregnant woman with a transverse lie:

“I sat down on the edge of the bed and began gently feeling the swollen belly. The woman groaned, stretched, dug her fingers into her flesh and crumpled the sheet. 

‘There, there, relax … it won’t take long,’ I said as I carefully put my hands to the hot, dry, distended skin. 

The fact was that once the experienced Anna Nikolaevna [the midwife] had told me what was wrong, this examination was quite pointless. I could examine the woman as much as I liked, but I would not find out any more than Anna Nikolaevna knew already. Her diagnosis was, of course, correct: transverse lie. It was obvious. Well, what next?”

I remember examining pregnant women after experienced midwives had already done so. They knew exactly what was going on, whereas I hadn’t a clue. We all played the game that I was the doctor and so had superior knowledge, but everybody knew it was absurd.

Bulgakov goes on:

Against a background of groans and screams Anna Nikolaevna described to me how my predecessor, an experienced surgeon, had performed versions. 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’.

I related to this in that I too got a distinction not in my obstetrics exam but in my medicine finals. Even at the time it seemed ridiculous as two weeks before the exam I couldn’t remember the valves of the heart. As I say to my daughter, I was good at passing exams not at practising medicine. Like Bulgakov (and, I’m sure, all doctors) I learnt more in moments of practice than in years of teaching.

In another story Bulgakov describes a doctor who became addicted to morphine and killed himself. I’ve known doctors who have become addicted to morphine, and I’ve known junior doctors who killed themselves. One young doctor I worked with stabbed himself in the chest.

But I haven’t known a doctor who murdered a fully fit patient. (I have known doctors who have given large doses of morphine to patients in severe pain near the end of life.) The drama of the Russian Revolution hardly appears in Bulgakov’s stories despite it being 1917-18, just as I hardly noticed the political traumas in Britain in the late 70s, but the last story tells of a doctor who against his will was require to report to the brutal Ukrainian army just as the Bolsheviks were about to take over. He tried to escape but was captured and told he would be the doctor to a cavalry unit and then tortured and killed once he had done his work. When asked to treat the sadistic colonel he used to opportunity to shoot him in the head seven times—and then managed to escape. Years later he was proud not ashamed of his act. Will any young doctor now be required to murder? Quite possibly somewhere on the globe.

Richard Smith was the editor of The BMJ until 2004.