Studying medicine

Matko Marusic, MD, PhD
Dean of the University of Split School of Medicine, Croatia

The author studied medicine from 1965 to 1970, at the Zagreb University School of Medicine, the capital city of Croatia, in the country that at that time was called Yugoslavia. It was under communist rule (until 1990). The home town of the author is Split, on the Adriatic coast, some 200 miles south of Zagreb; that is where his parents lived, and what he calls “home”. Interestingly, more than 40 years later, in 2008, he returned to live and work in Split, where he today serves as the Dean of the University of Split School of Medicine.

 


It is good to be a doctor, mainly because everybody knows what a doctor does. It is not management, communication theory, or international relations. When my brother graduated in architecture, he could not resist bragging about it to our grandmother. She did not know what architecture was; so she thought about it for a while and then
said, “Good, my son. Even that is better than digging.”

The only thing more beautiful than being a doctor is studying medicine. Medical students talk to everyone about their studying, with love and in detail; so they get on everyone’s nerves. However, it does not bother them because their goal is to explain that medicine is the hardest, most interesting, and most beautiful field of study in existence. And when people around them get fed up with their stories and do not listen to them any more, they take this as a sign that the listeners have been won over.

The decision

More than a third of medical students have a doctor in the family, but they all deny that it has any influence on their decision to study medicine. Even the children of medical professors have unclear reasons behind their choice of study, internships, or residencies; and their parents swear they play no part in their child’s choice of career. Only with those who don’t have a doctor in the family is it clear that their parents coaxed them into choosing medicine. The ones who make the decision on their own are, naturally, the orphans and the few children from the countryside who, for an unclear reason, want to be surgeons.

My case was relatively simple: I had no special talents, either for art or mathematics. I was a good student, and there was a doctor on my mother’s side of the family; so my father supported my choice. I later learned that my mother also favored the idea. However, when the doctor from my mother’s side of the family found out I was considering a medical career, he grimaced, symbolically spat at my feet, and said, “Oho, cousin, you would study medicine, eh?” What he meant was that there was no one in the whole family who was as smart as he—certainly not smart enough to become a doctor. While my father countered his remark with repetitive and somewhat less symbolical spitting, this only hardened my resolution to study medicine.

The entrance exam

Entrance exams evoke fear and dread in high-school graduates, and pure loathing in their parents. The entrance exam disrupts the parents’ habit of providing to their children anything they fancy. They want to ensure that their child will enroll successfully so that they don’t have to worry whether the child will succeed and so that the child does not have to learn too much—especially in the cases where the child does not like learning. This brings us to the question of corruption in the entrance exam.

It is generally believed that the entrance exam is rife with corruption. My father personally spread the rumor that a new Mercedes was the bribe of choice for securing acceptance into medical school, but even that was not sufficient without adequate connections. I asked him several times to tell me who had attempted such bribery with a Mercedes, but he just scowled stubbornly and said, “I swear it’s true.” The Communists happened to be in power and my father did not care for them, I think it simply suited him to believe the communist government to be as corrupt as possible. According to him, they were responsible for all kinds of corruption: low paychecks and living standards, executions without trials, and the prohibition of the Catholic faith.

The rumors of corruption in the entrance exam did not, however, stem from my father, but arose from the atmosphere of rampant corruption created by examinees and their parents just before the entrance exam. Everyone tried desperately to find connections. The connections of those who passed the exam attributed the success to their helping hand, and the connections of those who failed shrugged and said they were powerless against those with better connections in the Central Committee, the government, and the Parliament.

While the public focuses on a misguided belief in the theft of exams and interference with the results, the reality is that the most roundabout way of gaining entrance to the desired school is achieved by choosing the right private teacher before the exam, enrolling into a university with low standards, and later transferring to the university of the student’s first choice. When I enrolled at the Zagreb Medical School, I knew none of this. I believed in the importance of friendly connections. My father, just in case, spoke to my godfather, who was a respected member of an old Split family and thus owned a phone and could call Zagreb. My godfather was honest enough that, when I enrolled successfully, he admitted it was due to my own effort, but also said that he did call a friend in Zagreb who had told him that I would surely be accepted because I was very good.

A few decades later, when we were already young professors, I found out that one of my colleagues was studying the impact of various factors on successful enrollment to the medical school. I could not resist—I looked at the data for my own generation and saw something horrifying: those who had been the best on the entrance exam had been excellent students and gone on to become professors. When he heard this, my colleague destroyed the data, fearing to be accused of elitism. For a communist, that was almost as strong a charge as being a nationalist. Nobody gathered and analyzed the data later on, so only I know the truth.

The beginning

The newly enrolled freshman feels only the joy of success and the freedom from parental restrictions. He sees opportunities for new friendships and countless girls waiting for him; but does not see, feel, or even smell the great approaching dangers. The first danger occurs when the older students send him up to meet the Dean and the next danger involves the necessity of an immediate and serious approach to studying. Initially, a freshman does not realize that it is essential to start studying at once. He does not recognize that he needs to learn everything that is taught in a given week and eventually begins to believe that it is impossible to do so. He encounters the worst danger if he is convinced that the information assigned is impossible to learn and that soon a reasonable teacher will appear in the lecture hall and say, like in high school: “Children, we are just having a bit of a joke; you think I would allow such hardships to fall on you?”

Unfortunately, the exact opposite happens: nobody cares about the student. He slowly becomes a faceless number on a rapidly sinking ship with too few lifeboats. The quantity of information to learn accumulates rapidly in every subject—as all teachers claim that their subject is the foundation of medicine. Anyone who does not start studying immediately will have a hard time passing the final exam.

At the beginning of his studies the medical student is disappointed: there are no mentions of patients or medicine. Professors claim to be teaching human medicine but talk about cells; they drone about chemistry while one daydreams about stethoscopes; they use distilled water instead of blood and pipettes instead of surgical scalpels; they teach physics instead of x-rays and biology instead of diseases. If not for anatomy, the medical student might think he was attending a modern interdisciplinary postgraduate course.

I spent the first few nights of my academic career in Zagreb in the popular cafés discussing football with fellow Dalmatians who, like me, arrived to Zagreb to study. But it was nothing like Split. It soon grew cold, and I saw they were just passing time until it got too short to prepare for the exams. I stopped going out and started studying thoroughly until I graduated. My fellow Dalmatians later recalled:

When that kid came to Zagreb, we showed him the main streets—Ilica, Jurišićeva, and Šalata, and gave him directions to the Student Center. We gave him the list of books for the first year and valuable notes from the lectures. He then disappeared and was not seen for two years. Then he reappeared and said, ‘Guys, you should learn this subject from this book and not that one, this is not important, and be sure not to skip this….’ We did not see him for a while after that. He reappeared for graduation. He invited us to his dorm for a bite of prosciutto. He had no idea we were studying hard for our Pediatrics exam.

The middle

Halfway through medical school is the highlight of the experience: there are no more freshmen fears and still no worries about life after graduation. Everything is clear: where the university is, what the exams are, what should be studied and what not. Because there is no mention of treatment and the consequences of disease, the first encounters with patients are accompanied by excitement and enthusiasm. Working in the hospital requires wearing a white coat and a stethoscope. Girls like the coats, and boys like the stethoscopes. My stethoscope was smuggled from Germany, reputedly the best version available. The man who had acquired it determined that I was destined to become a doctor, so he gave it to me for free. My father thanked him and promised him free medical exams for the rest of his life.

The third-year student starts to recognize the distinctions between teachers and disgruntled administrators, and stops fearing the latter. He finds time to join a student club, and meets people who are interested in the branch of medicine in which he wants to specialize. This is the time of the best romances. The girls have grown up and become ladies, wearing coats and makeup, but they are still not thinking about marriage. There are no badly dressed third-year female students. The boys lag behind—they still don’t wash their hair regularly, not to mention their feet, and wear sporty clothes instead of proper underwear and coats. Some do try to experiment with ties, but mostly with dark shirts to match. They will develop into real (i.e. tie-sporting) doctors during their fifth year or when they graduate.

New faces appear every year and behave as if they have been at the school forever: they miss classes, cheat on exams, and go skiing. They are older students who have flunked a year. They stay with us for a single year, flunk again, and are forgotten. They reappear some twenty years later acting surprised that we don’t remember them. We are amazed that they are now respected doctors, assistants to ministers, or even ministers themselves. The theory that only good students become successful physicians proves to be wrong. There is a revered surgeon, the best in Croatia in his sub-specialization, who still mocks my faith in good grades.“I was a bad student, and look what I have become,” he tells his students proudly, they believe and admire him.

The end

The end of medical school begins imperceptibly during the fourth year. First you start losing friends: some are assigned to distant hospitals, others fall in love and are nowhere to be seen, while others have started studying seriously because the competition for a residency is at hand. Students, who did not drop out, despite difficulty with the theoretical subjects, suddenly start getting top grades and the best students start losing steam. A new class is in the making— indeed, some people open up when they reach the clinical subjects. They suddenly bloom into hundreds of flowers in the form of budding specialists with successful careers. It was like that in my day, and it is so now. My colleague whose daughter had problems with immunology told me the other day, “My daughter has bloomed after passing physiology and immunology and starting the clinical courses.”

As graduation approaches, guys who could not pass chemistry and physiology suddenly appear, knowing what they want and how to get it. They aim high, at residencies in gynecology, internal medicine, and surgery—the highest a student can aspire to. Once emancipated and self-assured, girls suddenly start thinking about anesthesiology, pathology, and cytology, leaving men to struggle with the prestigious residencies. In the end, everyone’s dreams come true, which is when the real trouble starts. But that has nothing to do with medicine.

Promotion ceremony

The promotion ceremony is the last flash of beauty in the life of a student. Parents bring prosciutto and wine from Dalmatia. Flowers are so plentiful that one doesn’t know what to do with them. The photographer also leads the promotion ceremony. Three professors attend: one reads a speech written by his high-school daughter; a second, a professor who rashly brags about attending the classical grammar school, tries to mutter some Latin phrases; and a third, who looks like an administrator, reads the names of the youngest doctors. We take an oath in Latin with a single word that we all say at the same time, but since everyone pronounces it differently, and no one knows what it means, the oath has a wobbly take.

I wake up the next day and don’t know what to do. There is nothing worse than graduating, because studying is thought to be more beautiful than working. Actually, anything is thought to be more beautiful than working.

Employment

Matko Marusic and his roommate in medical school

Just like rumors say about good students in America, I was offered a teaching position in Zagreb as soon as I graduated. My roommate and I had been working in the Physiology Department since our third year. When we graduated, we returned the key to the Professor and thanked him for assigning us to the assistant whose experiments we had been disrupting for three years. The assistant was an incredibly good human being, and he never told the Professor that we once spilled the sterile bone marrow cells that we had spent a whole day harvesting; or that some lab mice had once escaped from their cages, which we, after a valiant and humble chase, put into the wrong cages. All mice look alike, especially when inbred. In fact, so alike that even their owner—the acclaimed lab mouse expert, the assistant Filip Č.—could not tell them apart. Each time, it was good-bye to those experiments and we started over from scratch.

Nor did the Professor know that we had forgotten to wash the immersion fluid off a microscope lens, so that it dried and glued the lens to the microscope table. On the contrary, Filip Č. misinformed the Professor, telling him we were polite, diligent, and very, very intelligent—practically born to be teachers and scientists—and were especially skilled in studying the mechanisms of transplantation disease. The Professor believed him and, having a natural fondness for students with excellent grades, was very happy indeed when we graduated. Seating us in his most comfortable armchairs, he offered us positions at the Department. Dear God, dear mother, dear brothers—how much suffering the kindness and fairness of others could bring! What a burden the freedom of choice was! My roommate and I had intended to be doctors in Dalmatia and make our parents happy, loving the patients, furthering the practice, and, above all else, applying fairness and justice to the care of patients. A tiny portion of our minds, which we revealed to no one, hoped for the chance of conducting humble scientific research. I hoped to conduct my research on the subject of the frequent occurrence of kidney stones in Dalmatia, which I speculated was due to the over consumption of Swiss chard. My roommate wanted to research the cases of tuberculosis in the working class, suspicious of some capitalist plot. Then the Professor treated us to whiskey and his own cigarettes and tried to talk us into becoming his assistants, looked at us warmly, and was slightly surprised we did not accept right away.
He tried to convince us, talking and talking, showing wit, reason, and wisdom, until it got dark, and we didn’t have the courage to get up and turn on the lights. My roommate and I sat humbly, offering feeble resistance, which the Professor loved as he continued:

Everything is done for the patients, the people! The one examining the patient or giving him an injection is not the only one helping him. We create knowledge. One discovery can help more patients than the best doctor can in a hundred years of practice.
The times of the great shaman who touched, listened, and queried, and then gave the unexpected diagnosis are gone. Today, everything is done by machines and in accord with the diagnostic schemes. An unexpected diagnosis is reached in only one in a thousand patients.

It is better to help a child rather than a sick person. Teachers are more important to society because they create great men out of children. We create good doctors and thus we help serve patients the most.

Night had fallen, smelling linden trees and evoking memories of home. I gave in and asked for advice, taking into account my weaknesses and prejudices. The Professor did not get angry, but suggested my roommate and I enroll in the army, make up our mind there, and come back to him in six months. The Professor suddenly got up, turned on the light, took our keys, shook our hands and said, “Good luck. You can come sooner, whenever you reach your decision.”

I made my decision in the army, after exactly six months. I re-read Guyton’s book on physiology, enjoying every lesson. I was surprised that I could one day understand all of this as well as the Professor. For a second I regretted not having accepted his offer at once.

I returned from the army before the fall of the Croatian Spring and was immediately offered the position of assistant professor. Because, for the first time in history, the federal funds were divided between the states, Croatia opened 385 assistantships at the Zagreb University that year. My roommate returned from the army after the fall of the Croatian Spring, when there were no longer any positions open. So my roommate ended up working in a hospital, and I on the medical faculty. Very different fates at a glance, but essentially the same: the great Professor was our superior, and Filip, our teacher. They decided our paths and marked our future. We never begrudged them for it.

My parents were not glad that I had stayed to live in Zagreb and had taken a job in the Physiology department. While I was a student, my father kept saying only one thing: “You know what you are doing. Do you need money?” He revealed he wanted me to be a real doctor, and live on my own in Split—or even better, in our village—where he had already arranged for me some physical examination, even getting payment in advance—bacon, wine, and the promise of prosciutto. When he saw I was adamant that I wanted to live in Zagreb, coming to Split only during the holidays, he asked, staring at me from across the table:

“You mean to stay in Zagreb?”

“I do.”

“I don’t like it, but if that is what you want…”

He then went into the other room and brought two thousand German marks, mumbling “there’s more,” and brought my little brother’s piggy bank shaped like a chicken, broke it apart, and gave me the change in it, totaling the amount to two thousand one hundred and twenty two German marks: “That’s all I have, there is no more. If you want to stay in Zagreb, you’ll need an apartment. Here.”
And so I used his money to buy my first apartment. If someone does not understand how I did it with so little money, he wouldn’t be able to even if I explained it. My father liked coming to visit me in Zagreb. He spent his time exploring the market, marveling at how much cheaper the beans and most everything else were in Zagreb. He could see I was happy and didn’t even try to understand what I was doing. He only worried a little when I took the train to Zagreb after visiting Split.

“Beware of the Communists,” he warned me, “It’s best to be quiet.”

And when I called to ask him what he would like me to bring back from a conference in New York, he said, “Whatever you like. You could bring a piece of dried codfish.”
My mother also wanted me to stay and live in Split with them, to get married and have children that she would take care of (She didn’t have faith in my father’s savings and didn’t think anyone could buy an apartment on his own). She took no part in our discussions; she knew men shared the same opinions because they were harsh and unreasonable—however, all would pass eventually, and it would be her way in the end. She smiled kindly and gently, cooked with love when I came to visit, and waited for me to move back. And when she realized I would never move back, she sat on the other side of the table, sighed and said:

“My son, now that we are alone, and your father is not here to get angry—I would not dare to ask in front of him—tell your mother the truth. Whom will you tell if not your mother?”

“Ask, don’t be afraid.”

“Will you stay in Medical School or start working?”

 


 

MATKO MARUSIC, MD, PhD served for many years as a Professor of Physiology and Immunology in Zagreb University School of Medicine in Croatia and was recently appointed Dean of the University of Split School of Medicine, in Croatia. His mother proved right; he is now with her in Split, and she tenders him as she used to do 50 years ago. He has published four fiction books. This essay, translated from Croatian, is the first story of his book Medicina Iznutra (Medicine from Inside) published in March 2006 by Medicinska naklada Inc, Zagreb, Croatia. It is a 630-page anthology of 31 humorous stories about medicine comprised of four parts: Medical Studies, Research and Teaching, Clinical Work, After All. This book (see cover on the right) was Croatian bestseller for several months.