Medicine and the Arts
Commentary on an Excerpt From “Baptism by Rotation”
H
uman beings often go into labor and die at night. However, those who are not personally engaged in such momentous life events—and who are in a position to choose—generally prefer to be asleep then. Therefore, responsibility for the nighttime care of patients in extremis falls disproportionately on new doctors and/or doctors-in-training, a fact that has made overnight call their simultaneous boon and bane for generations. Insofar as it allows them to confront and treat medical emergencies with a minimum of interference from their superiors, overnight call can be their boon. To the extent that it casts them beyond their depth into life-and-death situations, it can be their bane. Nearly all clinical physicians have their own personal stories about their trials and tribulations on call, especially during medical school and residency. Facing a true medical emergency for the first time, without direct supervision, and at night, can produce a wide range of reactions, from exhilaration and inspiration to terror and panic. Night call is one of the universal formative experiences of medical training, a rite of passage akin to dissecting a cadaver or scrubbing in to surgery. It must be experienced firsthand to be fully understood, but compelling narratives can add valuable insight into such experiences for the initiated and uninitiated alike. In A Country Doctor’s Notebook, the Russian physician and author Mikhail Bulgakov (1891–1940) nearly turns such accounts of on-call emergencies into his own personal subgenre of the short story. Of this rewarding and underappreciated little book’s nine stories, five describe nighttime emergency cases faced by a newly qualified young doctor, recently stationed as the only physician in a tiny, isolated rural hospital around the time of the Russian Revolution. The stories are based on Bulgakov’s own experiences as a neophyte physician during his mid-20s, years before he left medicine to become a writer and decades before he gained posthumous international renown for his novel The Master and Margarita.
Academic Medicine, Vol. 90, No. 5 / May 2015
In these stories, told from the doctor’s perspective and represented here by “Baptism by Rotation,” Bulgakov vividly and urgently evokes a young doctor’s personal and professional coming of age, one emergency case at a time. In each story the young physician confronts a new and different medical crisis, usually prevailing and always learning. What differs from story to story are the specifics of each case and the nature of the young doctor’s responses. Over the course of the book, as his experience grows incrementally, readers sense the gradual blossoming of his clinical competence and personal self-confidence. “Baptism by Rotation” begins with the proverbial rude awakening of the young doctor who finds himself, in this case, facing an obstetrical emergency: labor complicated by a transverse fetal lie. Bulgakov vividly evokes the rapid stream of thoughts and emotions such a crisis produces. Excitement quickly transforms into fear of inadequacy, then near panic, which the doctor controls by an instinctual effort to remain—or at least to appear—calm. Maintaining his outward composure, the harried young doctor is resourceful enough to accept and follow the helpful cues given by the experienced midwife assisting him, while frantically scouring his memory for guidance from his extensive, though completely untried, book learning. The doctor’s grip on the situation, much like his grip on himself, is tenuous, with heroic success or frightful disaster hanging in the balance. The reader’s suspense regarding the clinical outcome mirrors the young doctor’s anxiety over his own skills, causing the reader to closely identify with the protagonist and his plight. At last the doctor screws his courage to the sticking place and acts, and when he does, the reader feels deeply invested in the result, both for the patient and the young doctor. The reader thereby serves as a witness, a godparent to the doctor during his rite of passage, his “baptism” as alluded to in the title. While fretting over his lack of practical experience and the futility (as he
sometimes sees it) of his book learning, Bulgakov’s overtaxed but intelligent doctor unwittingly takes the reader on a fascinating examination of medical epistemology. As his hands perform risky obstetrical maneuvers, his mind ponders the relationship between technical know-how (Aristotle’s techne) and factual knowledge (episteme). How do they come together? In the process of reading these stories one after another, the reader witnesses the mysteries of the learning process at work as the doctor gradually develops clinical judgment (phronesis). Given its time and setting, some anachronisms in “Baptism by Rotation” are apparent to today’s reader. For example, when the young doctor’s pride precludes him from admitting that he’s returning to his rooms to review a textbook before starting the difficult procedure, he gives as his pretext for stepping out that he needs to “fetch some cigarettes”—an explanation that startles modern readers, but which the other characters find perfectly reasonable. Additionally, the performance of a dangerous podalic version instead of a cesarean section (a ubiquitous procedure in the United States today) stands out. Nonetheless, though nearly 100 years old, A Country Doctor’s Notebook is still highly accessible and deeply relevant to doctors-in-training. It is an exceptionally true-to-life literary depiction of a young physician facing the onslaught of overnight call. Given recent trends toward duty hours limitations and more shift-based work schedules for physicians, today’s newest doctors may have fewer firsthand opportunities for such experiences. As such, the value of this book may be increasing. Certainly, it remains a richly rewarding reading experience, ripe for rediscovery. Clayton J. Baker, MD, CM C.J. Baker is clinical associate professor, Medical Humanities and Bioethics, University of Rochester School of Medicine and Dentistry, Rochester, New York; e-mail: [email protected]. See facing page for excerpt.
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Commentary on an Excerpt From “Baptism by Rotation”
H
uman beings often go into labor and die at night. However, those who are not personally engaged in such momentous life events—and who are in a position to choose—generally prefer to be asleep then. Therefore, responsibility for the nighttime care of patients in extremis falls disproportionately on new doctors and/or doctors-in-training, a fact that has made overnight call their simultaneous boon and bane for generations. Insofar as it allows them to confront and treat medical emergencies with a minimum of interference from their superiors, overnight call can be their boon. To the extent that it casts them beyond their depth into life-and-death situations, it can be their bane. Nearly all clinical physicians have their own personal stories about their trials and tribulations on call, especially during medical school and residency. Facing a true medical emergency for the first time, without direct supervision, and at night, can produce a wide range of reactions, from exhilaration and inspiration to terror and panic. Night call is one of the universal formative experiences of medical training, a rite of passage akin to dissecting a cadaver or scrubbing in to surgery. It must be experienced firsthand to be fully understood, but compelling narratives can add valuable insight into such experiences for the initiated and uninitiated alike. In A Country Doctor’s Notebook, the Russian physician and author Mikhail Bulgakov (1891–1940) nearly turns such accounts of on-call emergencies into his own personal subgenre of the short story. Of this rewarding and underappreciated little book’s nine stories, five describe nighttime emergency cases faced by a newly qualified young doctor, recently stationed as the only physician in a tiny, isolated rural hospital around the time of the Russian Revolution. The stories are based on Bulgakov’s own experiences as a neophyte physician during his mid-20s, years before he left medicine to become a writer and decades before he gained posthumous international renown for his novel The Master and Margarita.
Academic Medicine, Vol. 90, No. 5 / May 2015
In these stories, told from the doctor’s perspective and represented here by “Baptism by Rotation,” Bulgakov vividly and urgently evokes a young doctor’s personal and professional coming of age, one emergency case at a time. In each story the young physician confronts a new and different medical crisis, usually prevailing and always learning. What differs from story to story are the specifics of each case and the nature of the young doctor’s responses. Over the course of the book, as his experience grows incrementally, readers sense the gradual blossoming of his clinical competence and personal self-confidence. “Baptism by Rotation” begins with the proverbial rude awakening of the young doctor who finds himself, in this case, facing an obstetrical emergency: labor complicated by a transverse fetal lie. Bulgakov vividly evokes the rapid stream of thoughts and emotions such a crisis produces. Excitement quickly transforms into fear of inadequacy, then near panic, which the doctor controls by an instinctual effort to remain—or at least to appear—calm. Maintaining his outward composure, the harried young doctor is resourceful enough to accept and follow the helpful cues given by the experienced midwife assisting him, while frantically scouring his memory for guidance from his extensive, though completely untried, book learning. The doctor’s grip on the situation, much like his grip on himself, is tenuous, with heroic success or frightful disaster hanging in the balance. The reader’s suspense regarding the clinical outcome mirrors the young doctor’s anxiety over his own skills, causing the reader to closely identify with the protagonist and his plight. At last the doctor screws his courage to the sticking place and acts, and when he does, the reader feels deeply invested in the result, both for the patient and the young doctor. The reader thereby serves as a witness, a godparent to the doctor during his rite of passage, his “baptism” as alluded to in the title. While fretting over his lack of practical experience and the futility (as he
sometimes sees it) of his book learning, Bulgakov’s overtaxed but intelligent doctor unwittingly takes the reader on a fascinating examination of medical epistemology. As his hands perform risky obstetrical maneuvers, his mind ponders the relationship between technical know-how (Aristotle’s techne) and factual knowledge (episteme). How do they come together? In the process of reading these stories one after another, the reader witnesses the mysteries of the learning process at work as the doctor gradually develops clinical judgment (phronesis). Given its time and setting, some anachronisms in “Baptism by Rotation” are apparent to today’s reader. For example, when the young doctor’s pride precludes him from admitting that he’s returning to his rooms to review a textbook before starting the difficult procedure, he gives as his pretext for stepping out that he needs to “fetch some cigarettes”—an explanation that startles modern readers, but which the other characters find perfectly reasonable. Additionally, the performance of a dangerous podalic version instead of a cesarean section (a ubiquitous procedure in the United States today) stands out. Nonetheless, though nearly 100 years old, A Country Doctor’s Notebook is still highly accessible and deeply relevant to doctors-in-training. It is an exceptionally true-to-life literary depiction of a young physician facing the onslaught of overnight call. Given recent trends toward duty hours limitations and more shift-based work schedules for physicians, today’s newest doctors may have fewer firsthand opportunities for such experiences. As such, the value of this book may be increasing. Certainly, it remains a richly rewarding reading experience, ripe for rediscovery. Clayton J. Baker, MD, CM C.J. Baker is clinical associate professor, Medical Humanities and Bioethics, University of Rochester School of Medicine and Dentistry, Rochester, New York; e-mail: [email protected]. See facing page for excerpt.
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![Baptism by rotation [excerpt].](/assets/img/hold.png)
