BY ISAAC TANG

During the mid-year break, I came across a book in my sister’s collection that was small and slim (always a good sign!) with a rather benign, if not dull, title: A Country Doctor’s Notebook. I immediately assumed that it was yet another text about the joys and challenges of rural medicine to persuade more people to join its overburdened workforce. However, the blurb surprised me with some unexpected titbits of the book’s exotic setting and thrilling historical account – “twenty-five year old”, “lone doctor”, “depths of rural Russia”, “1916-17”, “eve of Revolution”. Moreover, this “lone doctor” is based off the first-hand experiences of the author himself, Mikhail Bulgakov (1891-1940).

With a large dose of dark humour and raw honesty, Bulgakov plunges into his collection of short but gripping tales. He uses many terms that are familiar to us as medical students but it is the stark differences in time, culture and medical knowledge that set these terms in shocking contexts, making the reading experience a surreal one at times. For example, we all know what an amputation is. But now imagine you are an intern on your first day as the only doctor in wintry, rural Russia without electricity and modern utensils and you have to amputate a girl’s leg. Plus, you have only watched an amputation… once. Some of us who have completed our women’s health rotation will know what a “transverse foetal lie” is and may have hazy recollections of a procedure called “internal podalic version” to help deliver this abnormally positioned baby. Again, imagine you are the same hapless doctor forced to do this for the first time in the middle of the night on an extremely distressed woman with only an obstetrics textbook to guide you.

For me, the anxiety is definitely palpable because I know for sure I would have collapsed under the same circumstances. Indeed, this poor doctor only has 2 midwives and a feldsher for assistance, with the footnotes graciously explaining that a feldsher is “a partly-qualified medical assistant” (emphasis mine). Despite his catastrophising thought processes and persistent self-doubt, the doctor, to my surprise and sometimes disbelief, carries out various surgeries and procedures successfully from pure determination and fortune. But Bulgakov also records some disastrous failures, including an unsuccessful internal podalic version which causes a baby to be delivered with a broken arm – and stillborn. In another instance, he accidentally pulls out a man’s tooth socket when he only meant to extract the tooth. In fact, when he sees the “enormous, jagged piece of gleaming white bone”, he almost “burst[s] into tears”. The doctor, that is. The patient has no idea what just happened as he is not told; he is only instructed to “rinse”.

This gives an appalling assessment of the culture of medicine back then – the paternalism and the lack of transparency. Bulgakov never records disclosing to his patients the fact that he has just graduated from medical school and has never done the procedures that he intends to perform e.g. tracheotomy, hernia repair. He does not even dare to inform his midwives or feldsher about that. Displaying a sense of arrogance and superiority also appears to be an expected part of early 20^th century medicine, especially towards the illiterate, impoverished and superstitious peasants Bulgakov encounters. There is no hesitation in directly denigrating a patient and their relations. A patient’s emotionally distraught grandmother is called “stupid” and promptly “pushed out of the room”. The doctor scolds and berates patients who do not accept his advice and he laments patients who present late in severe stages of disease. Understanding social determinants of health was clearly not core learning then, for he fails to appreciate the long distances his patients need to travel and the poverty and strenuous farming that characterise their difficult lives.

However, he does recognise that there are systemic problems that must be solved. Most of his stories are set at night, symbolising the overwhelming darkness of ignorance that he has to fight. He realises that health literacy and education are needed for a population to remain healthy. When he discovers an increasing number of syphilis cases in his catchment area, he begins to record his findings and reflect on how he can better convey the seriousness of the illness to his patients. Written before the discovery of penicillin, the proposed treatment of syphilis consisted of inconvenient, regular application of mercury cream on the skin that the patients had to adhere closely to. He also knows that he must have more doctors working with him to adequately meet his patients’ needs – a request to his employers that goes frustratingly unfulfilled.

His stressful working conditions are shown to have a great impact on his mental health. He never fails to remind us that he passed medical school “with distinction”. Yet he suffers from imposter syndrome, harbouring numerous fears that, out of shame, he feels compelled to hide behind a veneer of confidence and self-sufficiency. Before he runs off to peek at his textbook again, he tells his midwives he is merely gone to get cigarettes. Seeing approximately 100 outpatients a day and caring for 40 inpatients, he feels that he is gradually losing his personality. His irritable outbursts towards non-compliant patients likely signify his burnout. Thus, news of a violent blizzard is received “joyfully” as patients are prevented from reaching the clinic, allowing the doctor and his assistants a short-lived reprieve. In a tragic turn of events, he later receives news of a doctor acquaintance who loses his life after years of battling morphine addiction in secret. What makes things sadder is that Bulgakov does not reveal in this book that he himself had become addicted to morphine. Despite continuing to specialise in venereology, he eventually quitted medical practice to become a full-time writer.

In many ways, A Country Doctor’s Notebook shows us how far medicine has progressed and really instils in me a sense of gratitude for the improved conditions that we work in. But some issues touched on in the book still haunt us today in some way – poor health literacy, underserviced rural populations, the difference between medical school learning and actual practice, doctors’ mental health. Placed in an unfamiliar setting, this short book bursting with thought-provoking tales ultimately gifts us with a unique yet relatable perspective on what it means and what it takes to be a good doctor.