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Waiting. This is how you spend a lot of time studying obstetrics and gynaecology, especially if you’re a bloke – waiting in a corridor, having been asked to leave during an intimate examination, or waiting at the midwives’ station on the labour ward for a mother-to-be who is slow to dilate. Don’t think I’m ungrateful. After a patient and her husband have agreed to let me deliver their baby, I walk out of the delivery suite to find some scrubs and think to myself, ‘Wow! Permission to have a go in one of the most important events of their lives!’

O&G, like most of medicine, is something you can’t learn from a book. My favourite Russian writer-doctor is not Anton Chekhov but Mikhail Bulgakov, who describes with aching clarity the slow and at times humiliating road to acquiring what London taxi-drivers call ‘the knowledge’. (Shortly before his death from renal disease in 1940, Bulgakov wrote of medics: ‘I won’t call doctors murderers, that would be too harsh, but I will call them casual untalented hacks.’)

Bulgakov received his medical degree at the age of 24 from the University of Kiev, just a year before the 1917 revolution. There was a shortage of doctors, since many had been called up to serve on the Eastern Front during the First World War. As a result, newly qualified medics were not given the usual hospital internships for further training but were instead sent out to fill gaps in rural clinics.

A Country Doctor’s Notebook is a lightly fictionalized account of Bulgakov’s eighteen months as the only medic in a remote village in the north-western province of Smolensk. The stories set in the village, ‘thirty-two miles from the nearest electric light’ and only accessible by sleigh during the dark Russian winter, crackle like the fire in the stove in his benighted hospital quarters. And Bulgakov’s gentle laughter at his younger self, a panic-stricken doctor fresh out of medical school who desperately tri

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Waiting. This is how you spend a lot of time studying obstetrics and gynaecology, especially if you’re a bloke – waiting in a corridor, having been asked to leave during an intimate examination, or waiting at the midwives’ station on the labour ward for a mother-to-be who is slow to dilate. Don’t think I’m ungrateful. After a patient and her husband have agreed to let me deliver their baby, I walk out of the delivery suite to find some scrubs and think to myself, ‘Wow! Permission to have a go in one of the most important events of their lives!’

O&G, like most of medicine, is something you can’t learn from a book. My favourite Russian writer-doctor is not Anton Chekhov but Mikhail Bulgakov, who describes with aching clarity the slow and at times humiliating road to acquiring what London taxi-drivers call ‘the knowledge’. (Shortly before his death from renal disease in 1940, Bulgakov wrote of medics: ‘I won’t call doctors murderers, that would be too harsh, but I will call them casual untalented hacks.’) Bulgakov received his medical degree at the age of 24 from the University of Kiev, just a year before the 1917 revolution. There was a shortage of doctors, since many had been called up to serve on the Eastern Front during the First World War. As a result, newly qualified medics were not given the usual hospital internships for further training but were instead sent out to fill gaps in rural clinics. A Country Doctor’s Notebook is a lightly fictionalized account of Bulgakov’s eighteen months as the only medic in a remote village in the north-western province of Smolensk. The stories set in the village, ‘thirty-two miles from the nearest electric light’ and only accessible by sleigh during the dark Russian winter, crackle like the fire in the stove in his benighted hospital quarters. And Bulgakov’s gentle laughter at his younger self, a panic-stricken doctor fresh out of medical school who desperately tries to remember what to do in the face of rapidly evolving medical emergencies, will have echoes for newly qualified medics from Manhattan to Mogandjo. As the narrator drifts off to sleep on one of his first nights, haunted by strangulated hernias and other medical complications he fears might present themselves, the hospital cook bangs on the doctor’s door, announcing the arrival of a peasant woman in obstructed labour. Bulgakov starts to sweat, having seen only two live births at his medical school, and those completely normal. How to translate what he has seen on the zinc dissecting tables of the anatomy room, the cadavers like cold roast lamb, to the living, groaning patient before him (he has already had to bluff his way through his first above-the-knee amputation)? The midwife suggests a ‘podalic version’. The doctor concurs with a serious nod and then rushes off to his quarters – on the excuse of a cigarette break – to consult a German textbook of obstetrics. The lines in his edition of Doederlein well up in a blur before him: ‘the internal and combined methods must be classified as among the most dangerous obstetric operations to which a mother can be subjected . . . with every hour of delay the danger increases . . .’ Luckily for patient and doctor, the midwife can’t contain herself (she has seen it all before) and she breaks protocol to describe the intervention as they wait for the patient to slump under chloroform anaesthesia. The doctor hangs on every word and it is here that Bulgakov captures what real medical learning is all about. ‘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”.’ It is only after he has performed the version that everything in the textbook becomes clear: ‘all the previously obscure passages became entirely comprehensible, as though they had been flooded with light; and there, at night, under the lamplight in the depth of the countryside, I realized what real knowledge was.’ Light, or rather the lack of it, casts long, flickering shadows through the book, a series of short stories Bulgakov wrote in the 1920s for a popular magazine and a medical journal. Medicine is a source of light, as weak as the kerosene lamp on the narrator’s desk, which fails to penetrate the dark expanse of forest and steppe, made darker by the illiteracy and ignorance of the peasants he treats. The sense of profound isolation is compounded by doubts as to his ability to cope with the frightening responsibility he has taken on. Shattered sleep remains the lot of junior doctors but they can rarely be called out in the middle of a howling blizzard. Bulgakov is asked to attend a mortally injured woman in a distant village. He harrumphs as he reluctantly gets out of his first hot bath for a month. Then, pocketing a Browning automatic pistol and cigarettes and placing his medical bag in the back of a sleigh, he sets off through a snowstorm. But by the time he arrives, the woman is already dead. On the journey back, the blizzard blots out the road and swallows the sleigh, and the doctor has to fire several rounds to ward off a pack of wolves. The strain of Bulgakov’s medical induction made him succumb to morphine. His thinly disguised account of his own addiction to the ‘white crystals dissolved in 2 5 parts water’ and the devastation the chemical wreaked on both himself and those around him serves as an eloquent warning to all doctors under pressure and with access to a pharmacy – the British Medical Association estimates one in fifteen UK doctors has an alcohol or drug problem. It was his forced conscription by the White Army during the Russian civil war, and a severe bout of typhus, that drove Bulgakov to leave medicine and to write full time. However, he found no sanctuary in his new calling. Manuscripts and a diary fell into the hands of the OGPU, the forerunners of the KGB, and though Bulgakov remained at liberty, he lived in fear of a late-night knock on the door ever after. The Russian essayist Vitaly Shentalinsky wrote of the diary: ‘Like the doctor he once was, taking the pulse of a patient, Bulgakov followed the condition of his country and gave a correct and pitiless diagnosis.’ Unable to outwit the censor, his work unpublished, Bulgakov wrote directly to Stalin in 1930 begging for permission to emigrate (Bulgakov’s brother Nikolai was now a successful cardiologist in Paris) so he could be free to work. Such a letter usually ended with its author being either shot or sent to break rocks in the Gulag. But while the writer’s plays and stories we returned down by the drones of Glavlit (the government censor), Stalin admired Bulgakov’s work, seeing his play The Days of the Turbins at least fifteen times. The remote Red Monarch famously telephoned the writer in his flat to discuss the letter – at first Bulgakov thought it was a terrible hoax – but he denied him permission to emigrate; and the job given him as assistant director at the Moscow Arts Theatre amounted to little in terms of artistic freedom, for his work remained banned. ‘Each person ought to be a doctor,’ wrote Bulgakov, ‘in the sense of disarming all the invisible enemies threatening life.’ A new life is about to make its entrance at the Soviet-style hospital building in south London where I’m on rotation, the smell of antiseptic and boiled cabbage in the corridors and the no-nonsense nurses redolent of Russian clinics. My patient is fully dilated and groaning. The midwife tells me to hurry up. I open the delivery pack with basin, clamps and a pair of scissors with which to cut the cord. I fumble with sterile gloves so as not to touch their exterior and so contaminate them while pulling them on – luckily, the mother is too busy panting through another contraction to notice my shaking hands. The midwife then places her hands over mine so I know exactly when to stop the baby’s head from popping out too fast and so prevent a tear. She guides my hands round the baby’s neck once the head is out so as to find the cord and then helps me exert the right angle and force of traction on the anterior shoulder to bring the little one out. Under the delivery suite’s theatre lamp, a snuffling and then crying baby boy, his limbs and head moving like a clockwork toy, is handed to an amazed and tearful mother by an amazed medical student at two in the morning. The description of normal delivery in my own textbook is now crystal clear.

Extract from Slightly Foxed Issue 3 © Chris Bird 2004


About the contributor

Chris Bird reported from the former Soviet Union from 1992 to 1998 and wrote To Catch a Tartar: Notes from the Caucasus. He is now a medical student.

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