This article contains an excerpt from my unpublished memoir Bare Feet, White Dreams. It documents three cases of flagrant medical malpractice — among tens that I observed over five years of full-time employment at a high-ranking Russian academic clinic. The names of patients and the identity of the clinic are disguised for safety reasons. My intention writing this was not to name, shame, and defame, but to expose how these cases — and hundreds of similar ones happening in other institutions — are related to ubiquitous, normalized corruption in the country's public healthcare system.

In June 2013, the first drops of critical awareness seeped into my obscured mind in the very place that created most of my clinical depression at the moment – in my workplace. Over three previous months, continuing to work in conditions of semi-slavery and normalizing it with depression-driven ideas of my worthlessness and uselessness, I witnessed a few flagrant cases of malpractice. In fact, they weren't completely new to me. Previously, during my residency years I observed tens of similar cases, but back then they caused minor harm to patients’ health, and every time my supervisors and senior doctors rationalized them as "contingencies". Given their formal authority and my rookie position, from day one I was conditioned to dismiss the systemic character of malpractice which was related just as much to the medical illiteracy as to the greed for black money of those holding power in this system.

For example, elderly men with metastatic prostate cancer underwent a clinically useless procedure of surgical castration when their tumor had already become castration-resistant – because surgeons could charge a far bigger under-the-table bribe from their relatives for a surgery, no matter how little sense it made, than for a chemotherapy regimen, which was medically indicated for them. Imagine how much the emotional distress of having their testicles physically cut off compounded those men’s condition of living with incurable cancer that caused unrelenting, unmanageable, opioid-resistant pain in their lower back. But who gave a fuck about empathy or ethics there? The nurses said, Everyone makes a living however they can. Don’t judge and you won't be judged. In the same vein, there was a barbaric, pointless diagnostic procedure administered in men who were admitted for the surgical treatment of benign prostatic hyperplasia. Their diagnosis was already established, just like their indications for the surgical intervention were clear. They urinated with much difficulty even under normal conditions, but on admission, according to this idiotic protocol, 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”: this way, our collective was supposed to “pay tribute" to another bullshit dissertation approved 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 started to realize that it all didn’t happen by accident. Malpractice was systemic, driven by hustle for power, greed, vanity, and corruption, with little to no regard for evidence-based science, medical ethics, and the basic human rights of patients. And, in retrospect, those things pale in comparison to what I saw, and in a certain way even had to get involved with, in 2013 as an attending physician.

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, and visible presence of blood in the urine. His case was enigmatic – for more than a year now, no bacteria could be detected in his urine specimens despite tremendously elevated inflammation markers; his symptoms were also resistant to multiple oral antibiotic treatments. Upon admission into our clinic, he got a highly potent intravenous antibiotic — one normally reserved for septicemia and other emergency cases — but no improvement in his symptoms or laboratory findings followed. Then, he was switched to a different, “last-resort” antibiotic called vancomycin. Vancomycin was almost never administered in our unit, so the nurses didn't pay attention to the precaution about slow intravenous infusion indicated in the treatment sheet. As a result, the following night the patient developed a potentially life-threatening complication – angioedema, i.e. swelling of the throat, and acute urinary retention (inability to urinate), which required an urgent puncture and placement of a drainage tube directly into his urinary bladder. The antibiotic therapy was then continued in the correct regimen for another week, but his symptoms didn't improve anyway.

Then, without any solid reason but due to another “academic tradition”, a supervising professor who made rounds in our unit ordered to give the patient 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. Statistically, bladder cancer was rare in people of his age. His symptoms and medical history didn't align with it. Plain X-ray images, after all, were inconclusive. It was a widely known fact that chronic inflammation can cause changes that mimic tumor growth on gross examination.

As fate would have it, Evgeniy, another mafia member was now scouring the units for a young patient with bladder cancer. One month before, he had invited a doctor from Paris to come over 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 performed in our academic clinic before. It is highly invasive, reserved for patients with locally advanced bladder cancer who don't have metastases and are otherwise healthy. Of course, provided its complicated nature, this type of surgery implied an unprecedentedly high bribing fare. 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 trouble just a few days before: the patient he'd initially found now pulled back from the deal. The workshop had already been scheduled; the French surgeon had already been invited with his trip having been paid from the university funds. So now Evgeniy urgently needed a new guinea pig. And then he learned about that 36 y.o. patient in our unit. I was present in the surgery room when he found out about the "bladder tumor" diagnosed in this patient, and I remember his reaction clearly.

“I am so lucky!!!” he enthused. “I hope to God that this patient actually has Stage III cancer!!! Do whatever you need to have it confirmed!!!”

Just so you understand, Evgeniy was the exact same age as that patient. 36 years old. But his need to have a guinea pig for the workshop and his greed for money were so big that he, quite literally, “hoped to God” that another person would have an advanced, aggressive malignant tumor. Not only did he think this way, he didn't think twice before verbalizing it in front of his colleagues. Because in this system where corruption, malpractice, complicity, and dehumanization of patients were normalized and institutionalized, most people didn't give a shit about empathy or ethics. They made a living essentially the same way. And few black sheep like me were trained to remain silent and know our place.

A forceps biopsy was taken from the patient’s bladder mass, and the pathology report hesitantly stated the possibility of some atypical cancer. But it was still inconclusive – because the tissue sample was tiny and there was a lot of inflammation in the background. However, during this biopsy performed endoscopically, a couple of lesions similar in appearance were found on his urethra. Senior doctors of my unit, encouraged by Evgeniy, ruled that, aside from bladder cancer, this patient also had urethral cancer.

Again, despite having just three years of experience at that moment, I couldn't agree with it. There wasn't enough clinical evidence, and the evidence that was present didn’t add up. I understood that the patient required further evaluation focused on his prostate, the organ that his symptoms obviously arose from. Also, I couldn’t help seeing that, when making their snap judgments, my seniors were driven by underlying monetary pressures. Not only were they going to learn to perform 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 this intervention. They didn’t tell her that her husband was going to be a guinea pig, with no sufficient clinical indications for the surgery. They did tell her, however, that the surgery was going to be performed "by a highly qualified French surgeon whose exquisite services had to be paid for." In truth, his visit had been already paid from the university funds, and he would never learn about the under-the-table bribe that Evgeniy and his fellow mafia members were going to divide into cuts among themselves.

When the French surgeon arrived and reviewed the patient’s clinical data, he raised the same doubts about the diagnosis as those that I had, but our team assured him that their judgment was reliable, so they proceeded with the intervention. This was going to be a mutilating surgery – with the patient's bladder removed definitively, the urine secreted by his kidneys had to be collected into external urinary baga that he would have to wear for the rest of his life. His life, though, wasn’t expected 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, whose presence is very likely 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 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 deeply in the pelvis tore off and couldn't be removed. To much chagrin of the French doctor, when the removed bladder was cut across, a gross anatomical examination revealed no tumor at all. He said nothing. Everybody knew that the specimen would 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 got paralyzed, and there were 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 cancer, neither in his bladder nor in his urethra. The patient had a high-grade prostate cancer, extensively detected in the part of the prostate removed together with the urinary bladder, and that disease required a completely different treatment approach. That's why there was a rigid infiltration of the tissues surrounding the gland. That's why he had all those prostatic symptoms. Since a part of the prostate was left in his body, his outcome was fatal. But discharging him from our clinic, Evgeniy and his fellow surgeons extorted a huge bribe from his wife anyway. There was no truth and no accountability. A quick follow-up: in six months, the mutilated patient died from metastases spread all over his bones. And of course, no one was sued. 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 indicated by imaging studies, the treatment of choice was to extract it endoscopically, through a tiny puncture in her flank. The procedure was so simple that it required no more than a few days of hospital stay. However, my scientific supervisor put on airs in front of the woman about his experience in non-invasive treatments and recommended that she undergo shock-wave ultrasound therapy – a method reserved for much smaller and lighter stones, because it only breaks them into fragments but doesn't physically remove them – the fragments are supposed to be small enough to pass out with the urine. When she was admitted, I was appointed as her attending physician, so I was directly involved in exercising the treatment I knew was wrong. No wonder, the first shock-wave session was 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 stick to the shock-wave treatment. The second session cracked the stone somewhat, but the parts were too big to pass out. Then, my scientific supervisor insisted on the third session. Then, the fourth one. Overall, after three months in the hospital and six sessions of shock-wave therapy (the woman paid a bribe for each of them, of course), her left kidney stopped functioning altogether — both because of multiple shock-wave impacts and the fact that the whole length of her left ureter was now obstructed by the fragments of the original stone – none of them was small enough to pass 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 effectively 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 was running 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, he had initially considered treatment abroad. He had consulted various clinics in Europe, Israel, and the U.S., and they all independently confirmed the same tough truth about his diagnosis. There was no reliable biopsy to detect whether his tumor was benign or malignant, with the chances of cancer estimated at 80% according to CT images. 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 malignant, surgical treatment was his only salvation – unlike many other kinds of cancer, renal 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 new 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. The removal of one kidney increased the chance of renal failure in the long haul — in the event that the remaining kidney developed some disease — and so it theoretically decreased his life expectancy. He was willing to go to all lengths to avoid that.

Then he learned that certain surgeons in 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 renal surgery whatsoever. However, he had a huge experience in scenting cash. So he snowed the patient into believing that his tumor technically 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 rare opportunity to get huge 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 without removing the kidney. Unlike most of our patients, this man was rich enough to 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, so he told me and the head of my unit that he wanted the patient to undergo surgery and be discharged as soon as possible. Just so you understand, a patient's discharge day was also the under-the-table payday, so he obviously wanted to get his hunk of cash before leaving for the vacation. As a result, he scheduled the intervention just in three days after suspending the aspirin therapy that the patient had been receiving for his ischemic heart disease. The usual term of suspension of blood-thinning medications before major surgeries ranges from ten to fourteen days. I told the head of my unit about this 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 allegedly artful job. After a 25-cm-long incision in the patient’s upper abdomen (in 2013, “artful” surgeons in Russia knew no laparoscopy, of course), the wound started to bleed profusely. The bleeding gravely impaired tissue dissection and visualization, but it was more or less 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 had shown, 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 indicate the tactic for such cases: if partial removal turns out to be technically unfeasible during the intervention, the surgeon should proceed to the entire removal of the kidney.

But what did the credentialed, tenured 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 lay, according to his approximation. The size of this piece was about 1 cm, while the tumor dimensions exceeded 2.5 cm as shown by the CT scans. 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 this was happening in reality. Like, are you kidding me? Do you leave one half of the most probably 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 of the shitshow. A few hours later, in the ICU, the patient developed a grave postoperative bleeding. Hemostatic agents were administered in ginormous dosages, and fortunately, the bleeding was staunched. The next day, though, a rebound effect followed. The patient now got pulmonary embolism – a severe complication with the 80% mortality rate, in which blood clots form in the veins of legs, 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 and managed in a digital 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 – because 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 me this question, too, and how could I tell him the truth that I had borne witness to? What was my word against the word of a highly honored and respected professor, one of the bosses in this 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 to 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 as 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 because I realized it was already useless. 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. The warfarin treatment precluded the possibility of any other surgical intervention for at least one year, so now, even if he learned the truth, there was no way he could have his cancer-stricken 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. In Europe or Israel, for the same amount of money, he could have had his kidney removed radically via laparoscopic approach, could have been effectively cured and discharged after three to four days of hospital stay.

---

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 ruined, at the cost of the money they handed under the academic tables, for the supposedly highly qualified medical services? This is where my delusional logic started to collapse. Critical awareness kicked in. My depression and my disgust with normalized corruption at work didn't mean something was wrong with me. They weren't “all about my twisted perception”. There was the shift: I realized 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.

Check out related pieces of my research: