Chapter 36: Introduction to the Practice of Medicine

August 26, 1985, McKinley, Ohio

"I am SO glad I managed to get a parking sticker!" Elizaveta said as she got ready for school on Monday morning.

"Riding the bus is beneath you now, Princess?" I teased.

"Watch it, husband! If I remember, YOU said you drove to school starting the moment you got your driver's license."

"Sudden memory lapse?"

"I'll give you a memory lapse!" she growled but then laughed. "Do you have any idea what time you'll be home?"

"I'm not sure. Remember when we talked about the schedule, I said things were divided into blocks? Well, this week is basically introductory, and it's basically all lecture, 8:00am to 5:00pm. Next week, we start three different blocks — Foundations of Medicine, which is basically a combined anatomy, histology, and microbiology course. That's in the mornings, three days a week until Spring. The other mornings are blocks for epidemiology and physiology. We also have our Practice of Medicine block which is two hours three days a week, Monday, Wednesday, and Friday, from now until Christmas."

"You'll be home for dinner, though, right?"

"Yes. Absolutely. The only question will be Tuesdays, starting next week, when we have our clinical medicine sessions. We'll be at the hospital, a clinic, or in a doctor's office, and rumor has it that sometimes those run long."

"You see patients before you've had any time to learn?"

"That's part of learning how to be a doctor — watching other doctors do it. According to the student handbook, we can't do anything at all except watch and take notes. During our second year, we'll be allowed to take histories under direct supervision, IF the doctors allow it. That's not common, though."

"What about the study group?"

"They'll be here tonight, though I'm not sure how long it will go. I suspect this week will be a bit relaxed. Once we start the 'Foundations of Medicine' block, then we're going to be swamped."

"OK. I need to get going. See you tonight!"

I kissed her, and she left the cottage. I had about ten minutes before I had to leave to meet my group for breakfast in the cafeteria. Fran had suggested, and we'd all agreed, that a 'kickoff' breakfast was a good idea, following on the tradition we'd started at Taft. I double-checked my satchel to ensure I had my notebooks, three-ring binder with looseleaf paper, two mechanical pencils, two pens, my pack of felt-tip pens, two highlighters, and a white eraser. My calculator was in a pocket of the bag as well, and I got the gum and hard candy Elizaveta had suggested and put it in a separate pocket from the calculator. Everything in order, I put on my ryassa, picked up my satchel, and headed out to my car. Fifteen minutes later, having swapped my ryassa for my medical coat, I had my breakfast tray and sat down with the rest of the study group.

"Once more unto the breach!" Fran declared.

"When did you guys start this tradition?" Peter asked.

"Second semester, wasn't it, Mike? Fran asked.

"I think so, yes. That's basically when we kicked off the medical student study group at Clarissa's encouragement."

"You guys seem too relaxed," Peter said.

"There's going to be plenty of time for stress later, Peter," I counseled. "This week, they're going to teach us the history of medicine and what it means to be a doctor."

"And remember," Clarissa said, "everything this year is Pass/Fail, though you can get 'Honors', if you pass. That means that there is effectively no difference between a D-minus and an A-minus. To me, that takes off a load of pressure. Petrovich here, though, he's going to be near-suicidal if he doesn't get 'Honors' in everything."

"The old me, maybe," I said.

"Right!" Clarissa said, shaking her head. "Even as relaxed as we managed to get you at Taft, you STILL fretted over every point!"

"And he was valedictorian to show for it," Sandy said.

"Don't let Lissa kid you," I replied. "She was just as concerned about every point as I was."

"Mind if I ask your MCATs?" Peter inquired.

"98th percentile for me, 97th percentile for Clarissa."

"Wow! And what's with 'Petrovich' and 'Lissa'?"

"Russians have diminutive names for just about everything," Clarissa said. "So he calls me Lissa. Best friends call each other by their patronymic. He's Mikhail Petrovich Loucks, so being his best friend, I call him Petrovich."

"My birth certificate actually says 'Michael Peter'," I said. "I'm named for my grandfather and my father, which is fairly traditional for Russians, but my mom elected to use the English versions of my names on my birth certificate."

"So anyone who was a friend would call you that?"

"Anyone not from the church," Maryam interjected firmly. "I would call him 'Deacon Michael', 'Deacon Mike', or just 'Deacon'. Because his church is Russian, people from church might put 'Father' in front of any of those, but that's not the Arab tradition."

"But you're both the same religion, right?"

"Yes," I replied. "The US has a number of ethnic jurisdictions because of the Russian Revolution. The territory of North America was traditionally under the Patriarch of Moscow until then. But explaining it would probably take as long as today's lecture on the history of medicine!"

"We should eat," Sandy observed, looking at her watch.

We all ate our breakfasts, returned our trays, and headed for the main lecture hall, where we joined the other 123 first-year students. As had been our practice at Taft, we sat close to the front of the room, though neither Maryam nor Peter was thrilled with our tradition.

"Good morning! I am Doctor Vivian Underwood, and this is the Introduction to the Practice of Medicine, a week-long course which will provide you with a history of the medical profession and familiarize you with the duties and responsibilities of a physician, including most specialties. On Wednesday, you'll have a full First Aid course to supplement your CPR cards, and then on Thursday, we'll cover the professional growth necessary to become a physician and practice medicine, covering intellectual, emotional, psychological, moral, and, as appropriate for your situation, spiritual growth. On Friday, we'll break into small groups for discussion of everything we've learned.

"You are, as of this moment, a physician in training, and your every thought, word, and deed will be evaluated to ensure you are worthy of the title 'doctor'. This examination is NOT limited to your coursework but to every moment of your lives. This school, the hospitals and clinics where you train, and the State of Ohio all require you to be of excellent moral character in addition to being properly trained and skilled in the practice of medicine. You can flunk out of this school on moral or ethical failures just as you can on coursework.

"That said, the number one reason people leave the program or are dismissed from it is psychological failure. The coursework is not easy; it is, in fact, very demanding. Our profession, like few others, has little or no room for error and lives always hang in the balance. We train hard because what we do is difficult, and the public puts their trust in us to heal them, not harm them. The demands of your training will push you to your limits and probably beyond. Do NOT ignore the warning signs. If you see the signs, seek help from Student Health Services immediately. Nobody will look down on you or hold it against you.

"Our basic course objectives are to instill in you the importance of personal integrity, duty, altruism, patient confidentiality, and professionalism. In addition, we want you to understand the obligations and responsibilities of being a physician-in-training. And finally, to encourage mindfulness and self-reflection with the goal of self-improvement.

"Grades this first year are Pass/Fail, with the potential to earn 'Honors' in each class, usually indicating a score higher than 95%. Your grades will be a mix of test scores, lab scores, discussion scores, group scores, and evaluation by the teaching staff. A perfect set of test scores means nothing if you do not properly interact with your fellow students, the faculty, and the patients you will see. You can, and I've seen it happen, fail 'bedside manner' and be dismissed from the program.

"As for groups, I strongly encourage you to find study partners. Our experience shows that groups of four or five work best, but it really depends on you and your study partners as to the most effective size. While it is possible to get through medical school as a loner, you will have to work twice as hard as any other student, and you won't have anyone with whom to discuss your lectures and exercises. You will also have to find ad hoc partners for some blocks where you work in teams. A recent development that also seems to work is a group of six for anatomy, composed of two study groups of three, but with some mixing between the groups. Again, figure out what works for you as quickly as possible. If you don't, you are going to fall behind and struggle. And if you struggle with the foundation of your training, you're going to really struggle during your second year.

"Let me lay this out for you as plainly as possible — the strongest indicators of failure are trying to go it alone, ignoring your physical, emotional, and psychological health, failing to develop good study habits, not sleeping enough, and not eating right, in that order. Those reasons account for more dismissals or students leaving the program than an inability to learn the material. You are all extremely intelligent, or you wouldn't be here. That might have been enough in High School and for your undergraduate degrees, it won't be here. No matter how smart you think you are, someone smarter than you has left the program either voluntarily or involuntarily.

"Now, hopefully, I have your attention, and we'll begin the lecture in Ancient Egypt, with the priest-physician Imhotep eventually being deified as the god of medicine. The Egyptians built on the practice of what we would call 'medicine men' who used herbs in an attempt to cure illnesses and developed numerous medical techniques, though the record is spotty, and there are gaping holes in our knowledge of Egyptian medicine. One important thing we do have is the Kahun Gynaecological Papyrus, which describes gynecological diseases, contraception, fertility, and pregnancy. The treatments were rudimentary, but they do appear to have been effective in some cases.

"Next, we turn to Ancient Mesopotamia, where we have evidence of the formal practice of medicine dating to two thousand years BC. The Code of Hammurabi actually set out fees for surgeons and punishments for malpractice, and sometime just before the turn of the first millennium BC, the Diagnostic Handbook was written by a scholar named Esagil-kin-apli of Borsippa. It compiled the collected medical knowledge, including concepts such as diagnoses, prognoses, physical examinations, and prescriptions.

"Of course, it also included magical incantations alongside therapeutic measures such as creams, herbs, pills, and bandages. And despite the sniggering I heard at 'magical incantations', it contained logical methods of diagnosis and the use of observation to determine the correct course of treatment and the likely outcome. And, for continuity, if you review the earliest versions of the Hippocratic Corpus the influence of Babylonian medicine is quite obvious."

The lecture continued for two hours and we had our first break to get coffee and use the restrooms at 10:00am.

"Anyone remember seeing Scared Straight?" I asked as we sipped our coffee from styrofoam cups just outside the lecture hall.

"She sure didn't mince words," Maryam observed. "I'm glad we have our study group and anatomy group set."

There were nods of agreement from everyone.

"She's moving a mile a minute!" Sandy groused.

"The course outline says that this part isn't graded," Maryam observed. "It's the small group discussions on Friday that generate the grade."

"Rumor has it that the only way to fail this block is to not show up," Fran said.

"That makes sense," I replied. "I am going to stop in the bookstore at lunch and get the book she mentioned right at the end, just for reference."

"I think she blitzed the first two hours because we're at the point when things really start to change — with the foundation of the Royal College of Physicians of London in 1518."

"Which is congruent with a significant dividing line in European history," I said. "The Protestant Reformation was kicked off by Martin Luther on October 31st, 1517."

"Happy Halloween, Your Holiness!" Fran said with a smirk.

"Actually, to be entirely accurate, it had already started in Bohemia with Jan Hus, and Luther's intent was an internal debate. But the printing press had come into use, and things basically spun out of control, resulting in the Thirty Years War when Protestants and Catholics waged 'total war' against each other."

"Like in Northern Ireland?" Peter asked.

"A thousand times worse," I replied. "Maybe ten thousand times worse. But even modern Catholic scholars agree with Luther that things such as Tetzel's saying, 'As soon as the coin in the coffer rings, the soul from purgatory springs' were excessive. Heck, even the Council of Trent had a problem with the abuse of indulgences. But here I go again! It's time to get to class."

"Ronald Reagan and Carter?" Peter asked.

I chuckled, "Yes. One of our High School teachers, Mr. Black, loved to say that to people when they said silly or foolish things."

We re-entered the auditorium and took our seats. The second half of the morning class covered medical practice up to the first commercial Nuclear Magnetic Resonance Imaging machine, which was a serious improvement over X-rays but which was still mostly experimental.

When we broke for lunch, we went to the bookstore, and Maryam and I both bought copies of A Brief History of Medicine, which was, at a hundred pages, something I could read quickly. While I was there, I also bought another lab coat and asked for it to be embroidered. I paid for it and was told I could pick it up on Friday afternoon.

"Mind if I borrow your copy when you finish, Petrovich?" Clarissa asked.

"Not at all. We aren't going to be tested on it, so it's really just for my own knowledge and so I have something on my shelf to refer to if I ever need it. Anyone else is welcome to borrow it after Clarissa, so long as it's returned in the end."

The six of us headed to the cafeteria for lunch.

"Are we having breakfast every day?" Peter asked.

"That wasn't the plan," Fran said. "I know Mike will want to eat with Elizaveta, and I'd really prefer to eat with Jason most days. What if we agree on Mondays as a group and then other days as people want to?"

"Sounds good to me," Sandy replied.

"I'm in," Clarissa agreed.

Peter, Maryam, and I all agreed as well.

"What's the scoop for tonight, Mike?" Fran asked.

"7:00pm to 11:00pm at my place. If we don't have any studying, we can either just hang out or cut it short, but rumor has it that's not going to happen after this week. I have directions to my house for those of you who haven't been there."

I handed sheets of paper to everyone except Clarissa.

"Do we even need to meet this week?" Peter asked.

"I think after today, we'll want to discuss what's said so we're ready for Friday's small groups," Clarissa said. "I'd hate to look foolish or unprepared the very first time we're graded."

"And tonight will be a good time to get to know each other a bit more," I suggested.

We all got our lunches and sat at the same table we had that morning and began eating.

"Interesting dynamic in the room," Peter observed. "This morning, people were just having coffee or eating; now they're actively looking for study partners."

"I'm convinced we made the right choice," Sandy said. "We came here with a pre-built group of four who have already studied together. And we found two more right away, so we have a complete anatomy group."

We finished eating, and as we had time to spare, we decided to go outside and get some fresh air. Clarissa and I walked away from the group so we could speak privately.

"Any news on your parents?"

"Nothing good," I sighed. "My dad is shacked up with his girlfriend, and my mom is going to talk to the bishop."

"Damn," Clarissa said, shaking her head. "That really sucks."

"It does. Speaking of the bishop, I received a serious reaming for Tuesday night."

"Oh, give me a break! Seriously? One dance?"

I shook my head, "No, the dance was incidental. I was in public without my cassock in a situation not covered by any of Vladyka's stated exceptions. I broke his rule, and that's the thing for which he took me to task, noting that he most likely would have granted «ekonomia» had I asked in advance."

"But you didn't know!"

"Let's just say it was pointed out that if I weren't such a «говнюк» (govnyuk), I would have realized she was going to ask!"

Clarissa smirked, "And he pulls out the Russian to avoid saying 'shithead' in English!"

"Sorry."

"I was just surprised; you pretty much swore off swearing in Russian."

"Cute, Lissa."

"So what happened?"

"Basically, if I do it again, my butt will be in a sling, and I might well face serious discipline. As it is, I'm not even permitted to ask for leniency for a couple of months."

"Harsh."

"I've been a deacon for less than a month and already broke the rule. He's making a point, as he should."

Clarissa shook her head, "Well, nobody can say you didn't go into this with your eyes open."

"Elizaveta had a stern talking to for giving me bad advice."

"You ratted her out?! That's low even for you, Petrovich!"

"He would have asked if she gave her blessing, which is a key criterion for the bishop making a decision about such things. She's given me very good advice, otherwise."

"Oh?"

"Absolutely! When she's horny, she advises me to drive faster to get home!"

Clarissa laughed so hard she became teary-eyed.

"Well, at least you have your stress relief established!" she said when she finally stopped laughing.

"He did ask me to talk to him next week about my mom. I know he's hoping they'll reconcile, but I can't see it given what my mom said about trust being broken and my experience with Jocelyn, though that pales by comparison."

"Have you tried to talk to him since you saw him at the ceremony Friday morning?"

"I stopped by the house on the way to my grandparents' house on Saturday morning and then again on the way home. He was, as my grandfather put it, 'shacked up' with the young woman."

"Not something I would ever have imagined."

"Me, either. I'm going to try to call him after dinner tonight, but I'm not sure I'll reach him."

"Could you get the girl's phone number?"

"Sure, but how awkward is that? 'Hi, Holly. Is my dad there?'"

"Very awkward."

"I briefly contemplated telling Mrs. Vogel, but the last time I ratted someone out for adultery, my life went completely off the rails."