LITHUANIAN QUARTERLY JOURNAL OF ARTS AND SCIENCES
Volume 25, No.1 - Spring 1979
Editor of this issue: V. Stanley Vardys
Copyright © 1979 LITUANUS Foundation, Inc.
MEDICAL EDUCATION IN LITHUANIA:
Experiences of A Chicago M.D.
In 1977, not a single American medical student had yet studied in the Soviet Union, and to be the first to do so naturally required a bit of "red tape." After two years of applications to the University of Vilnius in Lithuania, a country where tourists are restricted to a five-day visit and where visitors are restricted to one-day passes out of the capital city, I was granted permission to complete my medical education in the country of my ancestors.
In a sense, my own medical education actually began in Lithuania during a five-day visit in 1973. At that time I attended a medical school lecture at the University of Vilnius. I recall that during a film of open heart surgery, a second year student fainted and had to be carried from the hall. Upon returning to the United States from my trip to Lithuania, I plunged into a grueling medical school curriculum at the Pritzker School of Medicine at The University of Chicago, a school that prides itself on its rigorous approach to the basic sciences with an emphasis on research.
The University of Chicago Medical School is an internationally renown institution, which among many other stimulating programs, allows students to spend three months at another University of their choosing, either abroad or in the States. At the end of my second year of Medical School I decided to apply at the University of Vilnius. My application forms were sent to Counsel Maliđauskas at the Soviet Embassy in Washington, D. C. and to Professor Jonas Kubilius, Rector (President) of the University of Vilnius. One year lapsed, and then finally I received a reply that my petition had not been accepted.
I knew for a fact that over the past few years there were an increasing number of guest physicians and professors from the Soviet Union who visited The University of Chicago. To me it seemed only fair that Chicago students be allowed to cross Soviet borders. Therefore, I sought out Dr. Daniel Tosteson, Dean of the Biological Sciences at The University of Chicago, for advice. He told me that he would be very happy to help me and that he would call his friend at the Moscow Academy of Sciences. I also asked professors who had personally hosted the Soviet scientists to write letters of recommendation on my behalf, urging the Soviet Embassy to accept my application to study the Soviet health care system.
On Christmas Eve of 1976, I received a telegram from the University of Vilnius, congratulating me on my acceptance, granting me a four-month stay, and I was to be there in ten days.
In February, 1977, after completing my ophthalmology in-patient ward responsibilities at The University of Chicago, I departed for the Soviet Union. Along the way I stopped at the renowned Moorfield Eye Hospital in London, and other hospitals and clinics in Oslo, Stockholm and Helsinki.
Although I had left Chicago on the 46th consecutive day of subzero weather, the evening I reached Leningrad my mood was even chillier. My fellow travelling companions, mostly American businessmen, and I were greeted by searchlights, machine guns and a host of border guards as we stepped off the plane. This type of welcome did not surprise me, nor did it surprise me that they confiscated a few American magazines, but I'm sure my less knowledgeable companions were shocked at our icy reception. Indeed, it was reminiscent of the cold war.
I arrived in Vilnius on February 17th, a day after Lithuania's Independence Day. Since letters had been crossed, there was no one to greet me at the airport. There was no official representative, nor was there the usual dozen or so relatives with flowers and gifts in hand. Nevertheless, I felt very much at home, and incognito, as no one at the terminal believed that I was from America.
Eventually, I was housed in a student dorm, in the section reserved for foreign academic guests—meaning those from Eastern European countries. I was the only student from a Western country in the dorm and probably the only American in all of Lithuania at that time of the year.
After a gracious welcome by the Foreign Affairs Bureau of the University, the authorities informed me that although I was officially accepted to do an internship at the University of Vilnius hospitals, I did not, in fact, have formal permission to enter a hospital. The previous year an American Lithuanian surgeon had assisted at surgery unofficially, and the authorities were very displeased when they learned of it. This stipulation entailed yet another application for a special permit from the Ministry of Health for a foreigner to enter a Soviet hospital. It was estimated that I might obtain the permit after a week.
In the meantime, I requested that I be able to sit in on the basic science lectures for beginning medical school classes. This was arranged by the Foreign Affairs Director of the Medical School. Director Dr. Antanas Adomaitis personally escorted me to and from these lectures, which were all conducted in Lithuanian. Although I am fluent in Lithuanian, the technical vocabulary was rather foreign to me.
I was quite amazed to learn that I had been awarded a stipend of 110 rubles per month. This is more than a beginning physician earns. It was a constant source of surprise to my relatives that "a capitalist would be getting wealthy even in a Socialist system."
By the week's end, I was granted the privilege of working in Antakalnis Hospital, a comparatively new, one-thousand bed hospital. A work schedule had been arranged; however, it was not one suited to my particular field of ophthalmology. Although I was planning to enter ophthalmology residency upon my return to the States in June 1977, I was informed that all ophthalmology facilities in Vilnius had been closed for renovation. Even though there was a recently completed 240-bed Eye Hospital in Kaunas, not far away, it remained nonetheless off-limits to all visitors, as indeed did that entire city. The plan proposed that I spend a month in internal medicine, a month in cardiac surgery, and the remainder in emergency surgery, all at Antakalnis Hospital.
Antakalnis Hospital was situated between the pine covered hills of Antakalnis, and it had a gray, aged look which afflicts all of Soviet architecture. However, once inside the hospital, the atmosphere changed dramatically, as if I had entered an entirely different world. The duplicate paperwork and tiring formalities were all left behind. The hospital physicians were so attentive and friendly that at times it was positively embarrassing. A visiting professor could not have been treated with more respect, nor a long lost wealthy relative with more consideration.
On my first day at the hospital, Professor Liubomiras Laucevičius scheduled rounds with an entourage of thirty medical students and house staff physicians. When I appeared on the scene in my starchy white clinical coat, comfortable house slippers, a casual student prepared to stand in the background and watch unnoticed, the professor quickly motioned me to the front row. He proceeded to explain to me each patient's history of present illness and the physical findings, Approximately half of the patients were Lithuanian, a third Russian and the rest Polish or Latvian. The professor translated when necessary.
In the clinic's complex, each room contained about eight patients. There were no partitions between beds. As we moved from bed to bed, only the professor and I would examine the patients. This preferential treatment so impressed the other medical students that they did not dare to talk to me for the next two weeks. After examining some 60 patients, the professor invited me to his office for refreshments.
Professor Laucevičius is an imposing figure in his eighth decade. He had trained in Vienna and he cherished his old Austrian stethoscope. While in his department, I learned that the title of "Professor" carried much more weight and prestige in the Soviet Union than it does in America. Physicians who were appointed to an academic post were called "candidates of science." He might remain a candidate for 20 to 30 years while he completed a second thesis. If he successfully defended his thesis (in the Russian language in either Leningrad or Moscow), he earned the title of professor. There were only seven such professors at this particular University hospital.
During my stay at the Vilnius Hospital, it soon became evident that the traditional academic disputes remained very strong there. The medical and surgical specialties competed rather than cooperated in their approach to medical problems. For instance, the cardiologist and cardiac surgeons rarely saw patients together, and even less frequently transferred patients to each other's service.
Nevertheless, the cardiac surgery unit was well-coordinated and disciplined, headed by Professor Dr. Algimantas Marcinkevičius, who is quite a popular figure in Lithuania. Considered among the best heart surgeons in the Soviet Union, Dr. Marcinkevičius frequents international cardiac conferences. His department reportedly has some of the best Soviet results in coronary bypass surgery. More than 1,000 cardiac catheterizations are performed annually by Marcinkevičius and his staff, placing this clinic among the top 50 institutions in the world. I was impressed with his "hopeless cases" such as a Soviet Korean who was turned away from other Soviet medical centers as a poor surgical risk, but made his way to Dr. Marcinkevičius for a successful coronary bypass and aortic valve replacement. Here, too, I had the privilege of actively participating in congenital defect repair, valvular and bypass surgical procedures. I frequently visited the intensive care unit for patient follow-up and participated in cardiac pulmonary resuscitation efforts.
Dr. Marcinkevičius is a thoughtful, forceful surgeon. He was both amiable and impressive. There was a staff joke about his trip to the Dallas Medical Center resulting in a few bad habits such as chewing gum during rounds, installing music into the operating rooms, and other American practices.
My third rotation was on the emergency surgical ward, where, again, I was very much involved with actual surgery, assisting numerous gall bladder, bowel, stomach and pancreatic surgical procedures. My preceptor, Dr. J. Narbutas and I would discuss patients in his office after morning teaching rounds until we were called to the operating room for surgery.
Once the case was completed, the other staff would take over the post-operative care. These guest privileges were in extreme contrast to the duties of a student in America, where one worked with patients and paperwork day and night, yet rarely did any surgery. Students in Vilnius were horrified to hear of the manual labor that medical students performed in the United States, and, of course, attributed this to capitalist exploitation of medical personnel. On the other hand, I was shocked to see the students leaving the hospital at 3 o'clock in the afternoon. Students there do not have any direct responsibilities for patient care as their counterparts do in the United States. Dr. Narbutas would often openly complain to his students that they were much too privileged a class in the Soviet Union, and that if they had to pay $5,000 a year from their own pockets for their medical education, they would certainly be working much harder.
My preceptors were eager for me to see the entire hospital. I once overheard someone quietly protesting to Dr. Laucevičius that I should not be assigned to the admitting rooms because these were so over-crowded and patients had to wait so long to be seen. But Dr. Laucevičius, who had visited Cook County Hospital in Chicago, assured the complainer that, in spite of all the hard work in America, conditions there were no better. (I could have told him that Cook County Hospital was our welfare hospital where care was provided for the indigent at government expense.)
On another occasion, I had just entered the operating room in surgical gown and mask, when I heard Dr. Marcinkevičius telling the staff to "find that American and put him to work." Everyone laughed when they saw that I was already in the room and had heard this remark.
I was frequently called "the American," although I considered myself a patriotic Lithuanian, something entirely compatible with my American citizenship. One day at a small gathering I protested that I was in fact "a Lithuanian from America." The group appreciated this remark and someone commented that they could now understand why they had sent someone like me over there. Again, I felt compelled to correct their Soviet way of evaluating me. I was not "sent over there," but came through my own individual efforts, only because I wanted to. I did not bother to say anything about personal freedom at this time.
Throughout my stay in Vilnius, I was treated with extreme hospitality and graciousness, both professionally and socially. Everyone went out of their way to make me feel at home, and to accommodate me as best they could. I was flooded with offers to go to plays, ballet performances, restaurants, or homes. Occasionally, complete strangers would invite me to dinner. Needless to say, I was flattered to be invited by the medical students to give a talk about the system of American medical education. One hundred and twenty students and staff physicians attended my hourlong talk instead of the expected group of 20.
For reasons which I still don't quite understand, everyone was curious and fascinated by the American educational system. It seemed that not a day went by that someone did not ask for a description or clarification. It was almost a certainty that at a party someone would inquire about the American unemployed, the American minority problem, and about our education. In Moscow, while perusing my luggage, the customs official began an interrogation about grade school education in America!
In the Soviet Union, students begin the six year medical curriculum at age eighteen. The training heavily emphasizes rote memory work and formal recitation. Textbooks generally are of poor quality and most of them are in the Russian language. Each year of the curriculum includes sequences of Marxist-Leninist philosophy, the scientific basis of atheism, Marxist economics, the history of the Soviet Union, the history of the Communist party, and civil defense.
In the fifth year students are assigned to a specialty area, then to an internship. The students vie for the positions in Vilnius and dread a rural assignment, but they seem to have little voice in this matter. There are no "residents" per se in this system to supervise and instruct the interns. Since as students they have few direct patient care responsibilities, the plunge from theory to practice is precipitous indeed.
Both in theory and practice, the Soviet health system is an unusual mixture of the archaic and the new. The doctors frequently emphasize: "We try to do the best we can with the means available to us." Some of the physicians in the Vilnius hospital where I worked experiment with a sophisticated aortic balloon pump, while other physicians still commonly use leeches, acupuncture, and mud baths to treat their patients. American medical literature is eagerly sought, but little is available. Physicians even learn Polish just to be able to read the more accessible Polish translations of American scientific journals.
The good physician is constantly frustrated in his patient care by lack of material supplies. Even the University Centers reflect the economic shortages of the general marketplace. (I found the scarcity of soap and toilet tissue in the hospital washrooms to be particularly annoying. Here, as elsewhere, people carry their copy of Pravda with them.)
I was amazed to discover that the socialized medicine system does not have enough money to pay for social workers. There are no social workers there. Doctors and hospitals, furthermore have neither secretaries nor copy machines. Doctors type their own operative reports on manual typewriters. There is an acute shortage of sanitary personnel. Because of guaranteed employment elsewhere, few people stay in these positions. To relieve a nursing shortage, unsuccessful candidates to the Medical School are given employment as nurses aides.
With regard to medical supplies, the Soviets and Americans are worlds apart. The most fanatic of American conservationists would be aghast at the measures taken to recycle. Surgeon's rubber gloves are resterilized, scalpels are resharpened, syringes are rewashed, metal intravenous catheters are used, glass bottles rather than plastic bags store the IV fluids. In contrast, even the average American taxpayer has little idea of the degree of the present throw-away system in his local hospital. Some of it is justified as protection against infection. Much of it is just plain calculated waste; it would be more expensive, in labor costs, to pay for washing and sterilization of equipment.
To a surprising degree, the condition of medical supplies reflects general economic theory. It almost seems that whereas the goal of the Soviet hospital is to be almost completely self-sufficient and a minimum burden to the economy, the goal of the American hospital is to stimulate consumer economy, spur production, encourage technology, and increase employment. In terms of world-wide medical health care delivery and use of available resources, the ideal system seems to be somewhere in the middle.
The most frequently heard argument against socialized medicine is that it eliminates the incentives to do a good job. As implemented in the Soviet Union, socialized medicine also eliminates the sanctions for poor or inadequate performance by physicians. There are no malpractice suits in the Soviet Union; they are not permitted. There are no peer Review Boards. The only incentive to do a good job is human concern for the patient and professional self-respect; these are noble, but occasionally fragile motivations. The pay remains the same, no matter how much work you do, what specialty you practice, or how well the work is done. One doctor joked: "In America you want to have many patients. Our business is not to have business." In fact, if you're technically competent and easy to get along with, other doctors will be calling you in the middle of the night asking you to take care of their more difficult patients. In view of such attitudes, considering the fixed pay scale and taking into account the requirement of group rather than individual responsibility, the Soviet physician is perpetually in a situation somewhat similar to that of the American in a residency training period.
The Soviet physicians, in turn, have their own reservations about aspects of the American health care system. I was repeatedly asked whether it was true that first aid in America is given by firemen. They found this quite amusing arid difficult to understand. I very much wanted to ride on the ambulance call, a key element in the Soviet health care system, as most people do not own automobiles. Reportedly, an ambulance on call arrives quite fast, and the patient receives treatment and transportation to wherever necessary, either the trauma center, infectious disease or obstetrics hospital, or the emergency surgery center, such as Antakalnis. Unfortunately, I was not permitted to do this.
After this refusal, my friends were astounded when near the end of my stay I received permission to spend a week at the new 240-bed Eye Hospital in Kaunas. At first it appeared that I would have to commute from Vilnius to Kaunas each day (four hours traveling time), but finally I was given permission to stay with my relatives in Kaunas.
Kaunas had been off limits to all foreigners, especially after the 1972 riots, and as far as I know I was one of extremely few Americans to reside there since the Second World War. I suspect that I would not have been allowed into Kaunas had it not been for some unofficial backing. The University of Chicago Ophthalmology Department Chairman, Dr. Frank Newell, editor of the American Journal of Ophthalmology, took a personal interest in my trip and wrote letters frequently, with much concern over my stay. Apparently my visit caused quite a commotion at the 1400-bed Kaunas Medical Center. I was told later that the day following my arrival everyone at the Center knew of the "visiting American from a family of nine children." (In Soviet Lithuania three children is considered a large family.)
I repeat, again and again, that the Lithuanians highly appreciate their visitors. A visitor is treasured for many reasons; most importantly, he is a window to the outside world. There is probably no other nation on earth where three million educated, progress-oriented people are so isolated from the rest of the world. Soviet culture by and large is now very familiar, but unacceptable, to most of the Lithuanian people. The Western nations, where so many of their relatives and friends reside, reman somewhat of an enigma to them, despite the easing of travel restrictions. During social gatherings, I frequently felt like a medieval troubadour. I was treated with the best of delicacies, and given undivided attention in return for news, entertaining anecdotes, and current songs from far-away lands.
There arises a paradox that in spite of the intractable isolation, there is no other region in the Soviet Union which has a more accurate picture of life and attitudes in the West. In the eyes of Russian visitors, the native Lithuanians think, act and dress so "Western" that in the Soviet Union the Lithuanian Socialist Republic is called "Little America."
However many misconceptions Lithuanians may have about life in the West, there remain more in the other Soviet Republics. In fact, Kaunas was recently unwittingly included in the strengthened TV broadcasting system of Poland which often show many American and European movies and programs. The people of Vilnius and Kaunas are most interested in Western life and in personal communications with the post-World War II emigration in the West.
In Vilnius, for the most part the weather is overcast and damp, but the sunny days are incomparable. A primitive freshness is continually present even in the heart of this greenest capital city of Europe. My last day was a beautifully warm spring day, and within the city limits a full-grown moose jumped out of the shrubbery and trotted alongside our automobile, an exquisite sight! Living within Vilnius I enjoyed what many American subarbanites search for but rarely find—a cultured urban climate within natural, clean surroundings. Given certain important changes, I was left with the opinion that Vilnius is an attractive place to establish a medical practice.
For me this three month experience also has a meaning which spans generations. Indeed it strikes me as a tragic commentary on Lithuanian history that in our patriotic Lithuanian family my grandmother had studied in Moscow, Russia, my parents in Tübingen, Germany, and I, now, in Chicago. It is one thing to be a visiting American citizen in this unwilling Soviet Republic, it is another matter entirely to have been an active member of a Lithuanian medical team and seen the Soviet medical practice which no other American has seen before. It seemed entirely appropriate that I symbolically concluded my medical studies and began my ophthalmological specialty studies in the land of my forefathers.