LAIR Conference Call: "A Young Doctor's Notebook" by Mikhail Bulgakov

1. "A Young Doctor's Notebook" Trailer (2013).

2. "A Country Doctor's Notebook" by Chris Bird

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.”

3. "Dr. Junkie: The Doctor Addict in Bulgakov's Morphine" by Victoria Tischler

The themes from A Country Doctors Notebook continue to resonate with residents today. They include fear of responsibility for others’ health and well-being, lack of confidence due to inexperience, and loneliness and boredom in regard to routine and mundane tasks. Bulgakov establishes the status and superior authority of the physician in his text by contrasting the ‘electric lights’ of the city which he associates with intellectual pursuits, with the darkness of the rural area in which he is based and practising as a resident. This lends emphasis to the elite position of the physician. Hospitals and health care environments remain hierarchical environments with physicians typically assuming leadership roles and residents reluctant to challenge authority (Lerner 2007).

Bulgakov became addicted to morphine after he began to treat himself for chronic abdominal pain, apparently following his wounding during active service. Other reports indicate that Bulgakov contracted diphtheria from a child patient during a tracheotomy. This operation is described in the story of The steel windpipe, also from A Country Doctors Notebook.

The story Morphine is about Sergei Polyakov, a resident who becomes addicted to morphine whilst working in a remote rural hospital. The narrative unfolds through Polyakov’s diary entries. He begins using morphine to treat physical pain, the first dose being administered by Anna Kirillovna, a married nurse with whom he begins a doomed affair. As his use of morphine increases, he notes its efficacy, not just for analgesia but also in dulling the emotional distress he experiences after his lover, an opera singer leaves him. As his addiction deepens, the tale reveals various justifications and rationalisations for his continued usage. His account echoes the sentiments of the ‘self-experimenters’ as he suggests that he is testing morphine to appreciate its therapeutic value, ‘I must give due praise to the man who first extracted morphine from poppyheads. He was a true benefactor of mankind. The pain stopped 7 min after the injection’ (p. 125) and, in justifying his usage, ‘It would be a good thing if a doctor were able to test many drugs on himself. He would then have a completely different understanding of their effect’ (p. 125)

The propensity for physicians to self-medicate is noted as Polyakov attempts to manage his symptoms using detached and scientific language, ‘The pain came again…fearing a recurrence of yesterday’s attack, I injected myself in the thigh with one centigramme [of morphine]. The pain ceased almost instantaneously’(pp 125–126).

As Polyakov’s addiction takes hold he begins to manipulate others, in particular Anna, and abuses his professional position, in order to maintain his drug supply, ‘Kindly give me the keys to the dispensary, I’m speaking as a doctor’ (p. 129) and ‘Are you going to do it [make up morphine solution]?’ She…answered quietly ‘Alright, I’ll do it’ (p. 129).

4. "The Agrarian Problem in Russia Before the Revolution" by V. Maklakov