This post contains an excerpt from my unpublished memoir Bare Feet, White Dreams. It details three cases of flagrant medical malpractice — out of tens that I witnessed over five years of full-time employment at a high-ranking Russian academic clinic. Patient names and data and the identity of the clinic are disguised. The intention of this report was not to name, shame, and defame, but to contextualize these cases in relation to widespread, normalized corruption in the country's predominantly public healthcare system.

Ironically, the first drops of critical awareness seeped into my obscured mind in June 2013 in the very place that created most of my clinical depression at the moment – in my workplace. Because over three previous months of being treated like a slave by the system and normalizing it with messages of worthlessness that me and my mates continuously got over university years, I also witnessed a few flagrant cases of malpractice. In fact, it wasn’t completely new to me. During my residency years I had seen tens of similar cases, but back then they resulted in minor harm to patients’ health, and every time practicing surgeons called it “a small inconvenience.” Given their formal authority and my rookie position, I was conditioned to dismiss what I saw and make excuses for my seniors.

For example, elderly men with metastatic prostate cancer got surgically castrated after their tumor had already become castration-resistant – because surgeons could charge a bigger under-the-table bribe from their relatives for a surgery, useless as it was, than for the chemotherapy protocol, which was medically indicated for them. Can you imagine how much the emotional trauma of having their testicles cut off compounded those men’s feelings of living with metastatic prostate cancer, which caused unrelenting, unmanageable, opiod-resistant pain in their lower back? But who gave a fuck? The nurses said, Everyone wiggles out a living however they can. Don’t judge them. In the same vein, there was a barbaric, useless diagnostic technique practiced in men admitted for planned surgeries for benign prostatic hyperplasia. Their diagnosis was already clear, just like their indications for the invervention. They urinated with much difficulty even under normal conditions, but on admission they were made to urinate in front of a few doctors with a thick ultrasound probe inserted into their rectum. This practice was another “academic tradition”: thus we were supposed to “pay honor” to a bullshit dissertation written in the clinic a few years before by an illiterate yet utterly arrogant Chechen who was now one of the leading members of the surgical mafia.

I observed many similar practices during residency, and with time I came to realize that it all didn’t happen by accident. Malpractice was systemic, driven by ego, greed, and corruption, with little regard for evidence-based medicine or patients' health interests. And, in retrospect, those things seem no big deal compared to what I saw, and even had to get involved with, now, in 2013, as an attending physician. What happened now was truly nightmarish. Even more nightmarish than my own depression, as dreadful and excruciating as it was.

Most importantly, despite the gaslighting so prevalent in the organizational culture there, I couldn't but see those cases were not just happening in my imagination. They were not fictional. They were real, observable, and palpable. Among them, three were especially flagrant, and I will share them with you to give you a taste of what Russian healthcare, the industry I worked in, was.

Case #1: Prostate Cancer

A 36 y.o. man got admitted with the clinical presentation of acute bacterial prostatitis – high fever, painful urination, constant pain in the perineum, blood in urine. His case was baffling – no bacteria could be detected in his urine despite highly expressed inflammation markers, while his symptoms were severe and, according to his medical history, long resistant to multiple oral antibiotic treatments. A highly potent intravenous antibiotic was administered for two weeks, resulting in no improvement whatsoever. Then, he was switched to a different, “last-resort” antibiotic. Since that antibiotic was rarely used and nurses didn’t pay attention to the special administration regimen prescribed by his attending physician, he developed a complication – angioedema (swelling of the throat) and acute urinary retention (inability to urinate), the latter requiring the urgent placement of a drainage tube directly into his urinary bladder through the abdomen wall. The antibiotic therapy was then continued in the correct regimen, but to no avail to his symptoms still.

Then, without any clear clinical indication but due to another “academic tradition”, a supervising professor who made rounds in the unit ordered to give him an X-ray while injecting a contrast medium into his bladder. The X-ray images showed something that looked like a mass inside his bladder, and at that point, all hell broke loose.

Senior doctors – the supervising professor, the head of my unit, and his attending physician – all argued that he had bladder cancer. Despite my relatively small clinical experience, I didn’t believe that. Because bladder cancer was very uncommon at his age. It was absolutely out of tune with his symptoms. X-ray images, after all, were inconclusive. It was a widely known fact that chronic inflammation can cause tissue changes that mimic tumor growth on gross examination.

As fate would have it, another mafia member was now scouring the clinic for a relatively young patient with bladder cancer. The thing is, one month before, he had invited a doctor from Paris to come and do a workshop on bladder removal surgery. Just so you understand, urinary bladder removal is one of the most complicated procedures in oncologic urology, and it had never been practiced in our academic clinic before. It is highly invasive, reserved for patients with locally advanced bladder cancer, without metastases, otherwise healthy, and with long life expectancy. Naturally, given its complicated nature, this type of surgery implied unprecedentedly high bribing fares. By learning how to perform it from the French colleague, our mafia surgeon planned to tap into a new huge source of under-the-table money. However, he'd run into a snag just a few days before: the patient he'd initially found now refused to undergo the intervention. The workshop had already been scheduled; the French surgeon had already been invited; all the arrangements had already been made. So now he urgently needed a new guinea pig. And then he learned about that poor 36 y.o. guy in our unit. I was present in the surgery room when he found out about the guy, and I remember his reaction clearly. “I am so lucky!!!” he enthused. “I hope to God that this patient actually has advanced cancer!!! Do whatever you have to do to confirm it!!!”

Just so you understand, he was the exact same age as that patient was. 36 years old. But his need for a guinea pig and his lust for money were so big that he “hoped to God” that his fellow human being had an advanced, aggressive malignant tumor. He not only thought so. He didn't hesitate to say it out loud in front of his colleagues. Because who of his colleagues, except me as a young research fellow, saw anything wrong about it in the system where corruption, malpractice, and the dehumanization of patients had been long normalized and institutionalized? Most of them made their under-the-table living essentially the same way.

Forceps biopsy was taken from the patient’s bladder, and the pathology report hesitantly stated the possibility of atypical cancer. But it was still inconclusive – because the sample turned out to be very small and there was a lot of inflammation in the background. However, during the biopsy procedure, a couple of small lesions in his urethra were also observed. Senior doctors of my unit, encouraged by the eagerly-hoping-for-cancer professor, ruled that, aside from bladder cancer, the patient also had urethral cancer. Again, despite my short experience at that moment, I somehow knew it couldn’t be true. Just because there wasn't enough evidence. And the evidence that was present didn’t add up. I realized that the patient required further evaluation focused on his prostate, the organ that his symptoms obviously arose from. Also, I couldn’t but see that, when making their snap judgments, senior physicians were driven by underlying monetary pressures. Not only were they going to learn this new kind of surgery, so “highly profitable" in the long run, but right now they were also going to extort a pretty fortune from the patient’s wife for the intervention. They didn’t tell her that her husband was going to be a guinea pig, with no sufficient medical indications. Instead, they told her that “the surgery was to be performed by a highly qualified French specialist whose exquisite service had to be paid for." In truth, that specialist’s visit was already paid for officially from the university funds, and he would never learn about the bribe that they were going to divide into cuts among themselves. Then again, practices like that were common and normalized in the system.

When the French surgeon arrived and reviewed the patient’s clinical data, he raised similarly valid doubts about the diagnosis as those that I had, but our doctors assured him that their judgment was reliable, so they proceeded with the intervention. This was going to be a mutilating surgery – with his bladder removed, the urine secreted by the patient’s kidneys had to be drained into an external urinary bag that he would have to wear for the rest of his life. His life, though, probably wasn’t going to be long: the estimated 5-year survival rate after this type of surgery is about 50%, due to inevitable kidney infection and other long and short-term complications, as well as the consequent growth of occult tumor metastases, which is very probable due to the aggressive nature of bladder cancer. Moreover, in this particular patient, in order to excise the urethra (which ostensibly also harbored cancer), the entire length of his penis had to be eviscerated. The prostate was also supposed to be extirpated, in a single conglomerate with the bladder and the seminal vesicles. The gory procedure lasted for four hours. Due to a marked solid infiltration around the prostate, a part of it lying deep in the pelvis tore off during the extirpation. To much chagrin of the French doctor, when the removed bladder was cut across, gross anatomical examination revealed no tumor. The specimen, however, was supposed to be sent to microscopic pathology examination.

The patient spent two miserable weeks in the ICU. His urine drainage system repeatedly stopped functioning. The tissues of his eviscerated penis got infected. His bowel was paralyzed, and there was a number of other complications. Shortly after he was brought back to the unit, the pathology report arrived. I was shocked to learn that I had been right: there was no tumor in his bladder and in his urethra. The patient had a high-grade prostate cancer, extensively detected in the removed part of the organ, and that disease required a completely different treatment approach. That's why there was a rigid infiltration of the tissues surrounding his prostate. That was why he had all those prostatic symptoms. Since a part of his prostate was left inside his body after the surgery, his outcome was fatal. But on discharge from our clinic, the professor who steamrolled this disaster because he needed a guinea pig, nevertheless extorted a huge bribe from his wife. A quick follow-up: in six months, the mutilated patient died from metastases spread all over his body. And of course, no one was sued or held accountable. This was Russian healthcare in its full glory.

Case #2: Kidney Stone

A 56 y.o., otherwise healthy woman, was seen by my scientific supervisor for a minor problem – a 1.2 cm (.5 ") stone in her left kidney. Given the position, size, and density of her stone as shown by imaging studies, the most effective and safe option in her situation was to extract the entire stone in a single procedure via endoscopic approach, with no incision but through a tiny puncture in her flank. The procedure was so simple that it required no more than a couple of days of hospital stay. However, my scientific supervisor put on airs in front of her about his experience in non-invasive treatment and advised her to undergo shock-wave ultrasound therapy – a modality legitimately reserved for much lighter stones because it only cracks stones into fragments within the kidney but doesn’t directly eliminate them from the body – the fragments are supposed to be small enough and few enough to pass out naturally with the urine flow. When she was admitted, I was appointed as her attending physician, so I was directly involved in effectuating the treatment that I knew was wrong. No wonder, the first shock-wave session proved totally ineffective. The stone didn't budge. My scientific supervisor learned that, and instead of finding an ethical way to acknowledge his mistake and switch to the correct approach, he insisted that we continue the inadequate treatment. The second session cracked the stone somewhat, but no part of it passed out of her urinary tract still. Then, my scientific supervisor suggested the third session. Then, the fourth one. Overall, after three months in the hospital and six sessions of shock-wave therapy (the patient paid a bribe for each, of course), her kidney stopped functioning altogether, both because of multiple shock-wave impacts and the fact that the whole length of her left upper urinary tract had been obstructed by the fragments of the original stone – they were so big that none of them passed out. The damage was permanent, just so you understand. As a result of her treatment being guided by a credentialed specialist in one of the most “famous” academic clinics in the country, the woman lost her left kidney.

Case #3: Kidney Tumor

My most recent horror in June 2013, this one involved a 62 y.o. man who'd been diagnosed with a kidney tumor. For our clinic, he was an extraordinarily wealthy patient. The former mayor of a big city in southern Russia, now he ran a high-end real estate business. The fact that he owned a private helicopter was a good illustration of his wealth. Like the majority of rich Russian people (who comprise a tiny percentile of the overall poor nation), he had initially sought for treatment abroad. He had consulted various clinics in Europe, Israel, and the U.S., and they all independently confirmed the same tough truth. Biopsy was unable to reliably detect whether his tumor was benign or malignant. Since the possibility of kidney cancer couldn’t be ruled out, the tumor had to be surgically removed, and because of its position within the organ, it couldn’t be excised leaving the kidney in place. It had to be removed along with the entire kidney. If it was actually cancer, which according to his CT data was 75-80% probable, then surgical treatment was his only salvation – unlike many other kinds of cancer, kidney cancer is inherently resistant to chemo and radiation therapy.

The man didn’t want to lose his left kidney, even though he knew it was a paired organ. At his age of 62 (which is, by the way, above the average life expectancy for men in Russia), he was still leading a vigorous life. He had been already financially secure, but he was actively growing his business. His youngest son was eight months old now, so he planned to live many years onward in order to raise and provide for him. Entire removal of one kidney theoretically increased the possibility of him having renal failure in the long haul if the remaining kidney developed any disease, and thus it theoretically decreased his life expectancy. He was willing to go all lengths to avoid that.

Then he had read on the university's Website that our clinic had “an extensive experience of organ-sparing kidney surgery”. That’s how he came to see my scientific supervisor for a consultation. Of course, the patient didn’t know that this particular doctor, holding an honorable tenured degree, had no experience in kidney surgery whatsoever. However, he had a huge experience in scenting big money. So he snowed the patient into believing that his tumor in fact could be excised leaving the kidney in place. In order for it to happen, the man only needed to pay an enormous under-the-table bribe “for the artful surgery” performed by another professor. That professor, in turn, didn’t take the trouble to carefully review the patient’s CT scans – apparently, he also sniffed out a big hunk of under-the-table cash, so he immediately puffed up in front of the patient saying that he had such an extensive surgical experience that he was able to excise virtually any tumor leaving the kidney in place. Unlike most of our patients, that one could afford virtually any bribe, so he readily accepted the deal.

Again, when the patient was admitted, I was appointed as his attending physician, and that’s why I know this disgusting story in detail. My scientific supervisor, who was in charge of the patient’s pre-admission workup and management, was soon to leave for a vacation, and he told me and the head of my unit that he wanted the patient to undergo surgery and be discharged as soon as possible. Any patient's discharge was the under-the-table payday, just so you understand, and he probably wanted to get his hunk of cash before leaving for the vacation. This way or another, he scheduled the intervention just in three days after their first appointment and suspending the aspirin therapy that the patient had been receiving for his ischemic heart disease. The normal term of suspension of blood-thinning medications before planned major surgeries ranges from ten to fourteen days. I told the head of my unit about that unwarranted risk, but he blew it off. And here was the result. As the patient’s attending physician, I was present in the surgery room, performing the trifling role of holding retractors while the tenured professor was doing his supposedly artful job. After a ten-inch incision in the patient’s upper abdomen (“artful” surgeons in Russia knew no laparoscopy, of course), the wound started to bleed profusely. The bleeding seriously impaired tissue dissection and visualization, but it got somehow stemmed. However, when the kidney was eventually exposed from surrounding tissues, it appeared absolutely intact. This situation was predictable from the preoperative imaging data. Just as the CT images showed, the tumor was entirely submerged into the kidney pulp. There was no way to project its margins onto the kidney surface. Thus, there was no way to safely and radically excise it. European and American oncology guidelines clearly define the tactic for such cases: if partial removal is found to be technically unfeasible during the intervention, proceed to the entire removal of the kidney.

But what did the credentialed Russian surgeon do? He kept in mind that the patient had only consented to bribe for an organ-sparing surgery. This was the unwritten condition of the illicit bargain. So he just cut out a random piece from the part of the kidney where the tumor approximately lay. The size of this piece was about .5 inches, while the tumor dimensions comprised more than one inch according to the CT data. And that was it. At this point, he left the room and ordered the assistants’ team, including me, to suture the wound. I couldn’t believe what was going on. Like, are you frickin' kidding me? Do you leave one half of the supposedly malignant tumor in the body and finish the surgery? Well, that’s how “gods” of Russian healthcare did their job. I only hoped that the pathology examination would find the tumor to be benign.

And that was just the beginning. A few hours after such an “artfully performed” surgery, the patient developed a profuse postoperative bleeding in the ICU. Hemostatic agents were administered in ginormous dosages, and fortunately, the bleeding was staunched. The next day, though, a rebound effect followed. The patient developed pulmonary embolism – a severe complication with the 80% mortality rate, in which blood clots form in the leg veins, then travel to the heart, and then obstruct blood flow to the lungs so the blood can’t be effectively saturated with oxygen. Naturally, the ICU doctors quickly erased the records of hemostatic treatment from his case history. No one was willing to assume the blame for the corpse, and when medical documentation consisted of handwritten papers instead of being stored in a computerized system, it was easy to falsify anything. Of course, when the pulmonary embolism got confirmed, the ICU unit had no facilities to give him necessary blood tests. So for a few days, as the patient struggled between life and death, it was me who was running around different labs in two miles’ radius to deliver his blood specimens and bring the printed results back – in this mismanaged system, lab workers refused to tell me the results over the phone. After ten days, the patient eventually improved and was brought back to our surgical unit.

Many times, when his operating surgeon made rounds together with the entire unit’s staff, the patient asked him whether the tumor had been removed completely. And every time, he heard a confident "Yes" in response. He asked this question to me, too, and how could I tell him the truth that I had been witness to? What was my word against the word of a highly honored and respected professor, one of the bosses in the academic clinic? The pathology report arrived when the patient had already been discharged, and I was appalled to learn the truth. The removed piece of his kidney contained high-grade cancer. And I was the only person taken aback by the enormity of the situation. The operating surgeon, my scientific supervisor, the head of my unit – they all behaved as if nothing were wrong. The huge bribe was received, and it was divided into cuts according to the totem pole. When the head of my unit gave me my tiny cut, as an extra bonus to my tips, he told me, “Why do you even give a shit about this patient? Your share of the money is small, and so is your share of responsibility.” I didn’t say anything in response. Now my scientific supervisor made it clear for me that he would not only “ruin my dissertation” but also “drum me out of the clinic” if I gave the patient more information than my position of a paperwork-handling slave implied. So I had the intention of privately contacting the patient and telling him the truth, but then I was further devastated as I realized: there was already no point. The thing is, after his pulmonary embolism episode, the patient had to be put on warfarin — a yet more potent blood-thinning drug than aspirin, and this treatment had to be continued for at least one year to prevent embolism relapses. This medical precluded the possibility of any other surgical intervention for one whole year, so now, even if he learned the truth, there was no way he could have his cancer-harboring kidney removed elsewhere – embolism-related surgical risks would be too high.

This was the outcome. The patient suffered a potentially lethal complication after a highly invasive, oncologically useless surgery, and now, because of its repercussions, he had no chance to undergo another, truly curative surgery. He spent a pretty fortune on this “treatment” and was unaware that cancer continued to grow inside his body. For the same amount of money in the USA, Europe, or Israel his kidney would have been removed radically via laparoscopic approach, and he would have been discharged cured, after three to four days of hospital stay.

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Those blatant cases of medical malpractice, caused by senior doctors’ medical illiteracy, disregard for evidence-based science and unchecked lust for black money, finally sobered me up. Okay, I was severely depressed and believed that, as a young employee I got treated like shit because I deserved to be treated like shit. But what about these patients? How did they deserve to have their health irreversibly damaged, at the cost of their own, out-of-pocket money handed under the academic tables? This is where my delusional logic started to tumble down. Critical awareness kicked in. My depression and my disgust with normalized corruption at work weren't problems arising out of nowhere in my head. They weren't “all about my twisted perception”. There was the shift: I saw that my depression wouldn’t disappear on its own — because it didn't come about on its own. I realized that I had to keep going forward, on my journey towards a better life, certainly outside Russia and its hopelessly corrupt medical industryand, eventually, outside the medical profession.

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