Friday 18 May 2012
The Hair Issue, Part 2
"I've killed patients during my internship. . .I'm Learning"
"I've killed patients during my internship. . .I'm learning". Yes, that is a direct quote from the intern I have been working with. The statement is scary enough but when punctuated by an apathetic shoulder shrug and an air of indifference it was almost chilling.
I had been working with this intern on the endocrine service at Mulago Hospital for at least week when she made this revelation. She possessed what is perhaps the most dangerous combination of personality traits that a physician can have: apathy, lack of knowledge, disinterest in learning, dishonesty, emotional detachment, cockiness and poor work ethic. It is just a recipe for disaster.
When we first met, her lack of clinical knowledge, poor clinical judgement and laziness were obvious. She would stroll in around 8:30 and not be prepared for rounds. As an attending, I tried to coach her through history taking, physical exams, developing a differential diagnosis, and making treatment plans. I was hoping to help her "look good" for her Mulago attendings. She really was having none of it. If she saw me examine a patient, she would ask for my findings instead of examining the patient herself, write them in her poorly constructed notes and look expectantly at me to feed her the plan. If she did ever venture to develop a treatment plan, it was more often than not incorrect and thoughtless. But I still encouraged her to try. After about two days of this, I reminded her that at the end of this rotation, that she would be an independent medical officer who would have sole responsibility for the well being of her patients. This was met with a blank stare.
With every day, I was losing patience with her and beginning to feel my efforts were futile. I finally asked her why she became and doctor and why she was bothering to continue with her training. Unfazed, she replied that as a child she watched ER and was fascinated by George Clooney. Her parents "foolishly" encouraged her in her studies. As she began her clinical studies, she would cry when a mother's life was lost labor but now if she saw a woman giving birth on the side of the street, she would "hurry up and pass". Now, toward the end of her internship year, she feels that she is "numb, not even human". If nothing else, at least she is honest about who she is. When I asked her again why she would not consider going into another profession now, she said she thought this would be temporary and that once she finished internship and could practice in a better environment, things would be better.
Teaching her was an arduous task. She can quite delusional about medical information. I actually had to show her in print that Hepatitis B is not routinely transmitted via kissing. Even after this, she stated she would still go and "look it up on eMedicine".
Her apathy is epic. In reviewing a 30-somethinig year old patient who had cirrhosis and later developed a seizure while in the hospital followed by a new focal neurological deficit (which I discovered, since she had not bothered to examine the patient after his seizure), she could not understand why I would bother asking for neuro checks or a head CT because "hepatitis has a poor prognosis anyway". At least she was willing to write the consult to have gastroenterology see him for the hepatitis. She was actually proud as a peacock that she thought of that.
She her work ethic is some of the worst I have seen. She did say that with being paid what she calls "pocket change" during her internship, she has decided that she is not going to let the patient load or work break her back. So she does "what I can" and will do no more. On the weekend, she arrives at the hospital around midday. She cringed when I suggested she get to the hospital earlier than 8 am.
She is a danger to patients. It is one thing if there were upper level residents to pick up her slack. They have all been absent because they have exams (which I find ludicrous, but that is a whole other story). It would also be different if there was consistent supervision from the hospital attendings. But she is there, alone, mostly unsupervised taking care of some of the sickest patients that I have ever seen.
She has expressed a fear of needed to repeat this three month rotation in Mulago. She, however, has not yet made the connection that her actions (or lack thereof) are going to lead her right down that path. She is someone who I would fail without hesitation. On my last day working with her, she decided that she was entitled to have a life and would be taking a three hour lunch. This despite the fact that the majority of the patients had not been seen. It was the last straw for me. I reported her to one of the attendings in the department of medicine. I felt a bit of relief when it was revealed that her suboptimal behavior had been noted and that she was indeed in danger of needing to repeat the rotation.
So in stepping back and looking at the entire situation, it is hard to know how much of this is due to intrinsic personality deficits and how much is the culmination of years of working in a medical system that does not work.
I had been working with this intern on the endocrine service at Mulago Hospital for at least week when she made this revelation. She possessed what is perhaps the most dangerous combination of personality traits that a physician can have: apathy, lack of knowledge, disinterest in learning, dishonesty, emotional detachment, cockiness and poor work ethic. It is just a recipe for disaster.
When we first met, her lack of clinical knowledge, poor clinical judgement and laziness were obvious. She would stroll in around 8:30 and not be prepared for rounds. As an attending, I tried to coach her through history taking, physical exams, developing a differential diagnosis, and making treatment plans. I was hoping to help her "look good" for her Mulago attendings. She really was having none of it. If she saw me examine a patient, she would ask for my findings instead of examining the patient herself, write them in her poorly constructed notes and look expectantly at me to feed her the plan. If she did ever venture to develop a treatment plan, it was more often than not incorrect and thoughtless. But I still encouraged her to try. After about two days of this, I reminded her that at the end of this rotation, that she would be an independent medical officer who would have sole responsibility for the well being of her patients. This was met with a blank stare.
With every day, I was losing patience with her and beginning to feel my efforts were futile. I finally asked her why she became and doctor and why she was bothering to continue with her training. Unfazed, she replied that as a child she watched ER and was fascinated by George Clooney. Her parents "foolishly" encouraged her in her studies. As she began her clinical studies, she would cry when a mother's life was lost labor but now if she saw a woman giving birth on the side of the street, she would "hurry up and pass". Now, toward the end of her internship year, she feels that she is "numb, not even human". If nothing else, at least she is honest about who she is. When I asked her again why she would not consider going into another profession now, she said she thought this would be temporary and that once she finished internship and could practice in a better environment, things would be better.
Teaching her was an arduous task. She can quite delusional about medical information. I actually had to show her in print that Hepatitis B is not routinely transmitted via kissing. Even after this, she stated she would still go and "look it up on eMedicine".
Her apathy is epic. In reviewing a 30-somethinig year old patient who had cirrhosis and later developed a seizure while in the hospital followed by a new focal neurological deficit (which I discovered, since she had not bothered to examine the patient after his seizure), she could not understand why I would bother asking for neuro checks or a head CT because "hepatitis has a poor prognosis anyway". At least she was willing to write the consult to have gastroenterology see him for the hepatitis. She was actually proud as a peacock that she thought of that.
She her work ethic is some of the worst I have seen. She did say that with being paid what she calls "pocket change" during her internship, she has decided that she is not going to let the patient load or work break her back. So she does "what I can" and will do no more. On the weekend, she arrives at the hospital around midday. She cringed when I suggested she get to the hospital earlier than 8 am.
She is a danger to patients. It is one thing if there were upper level residents to pick up her slack. They have all been absent because they have exams (which I find ludicrous, but that is a whole other story). It would also be different if there was consistent supervision from the hospital attendings. But she is there, alone, mostly unsupervised taking care of some of the sickest patients that I have ever seen.
She has expressed a fear of needed to repeat this three month rotation in Mulago. She, however, has not yet made the connection that her actions (or lack thereof) are going to lead her right down that path. She is someone who I would fail without hesitation. On my last day working with her, she decided that she was entitled to have a life and would be taking a three hour lunch. This despite the fact that the majority of the patients had not been seen. It was the last straw for me. I reported her to one of the attendings in the department of medicine. I felt a bit of relief when it was revealed that her suboptimal behavior had been noted and that she was indeed in danger of needing to repeat the rotation.
So in stepping back and looking at the entire situation, it is hard to know how much of this is due to intrinsic personality deficits and how much is the culmination of years of working in a medical system that does not work.
Monday 14 May 2012
Camping, Murchison Falls and Chimp Trekking
This past weekend was a definitely a first for me. Though I strongly feel that I am not high maintenance (just maintained highly), there are certain things that I just don't do. Camping is one of them. I've NEVER been camping in my life. Bugs (many of which refuse to die if you just step on them), outdoor toilets, tents, no electricity, paying to rent a ratty towel, and cold water showers in an unspeakably filthy communal bathroom are just not my idea of a fun-filled weekend. But I am proud to say that I did it and survived.
So to go back to the beginning, this weekend was my second trip out of Kampala. A group of us ventured north to Murchison Falls. The first stop on our journey was the Ziwa Rhino Sanctuary. Though rhinos were once numerous in Uganda, they had been hunted and poached to near extinction by the 1980s with the last rhino seen in the wild in Uganda in 1983. In 2004, Ziwa was established to help breed the rhinos with the hope of eventual repatriation to the wild. The sanctuary allows pretty close contact with the rhinos. It was a hot trek in the bush but so worth it.
The following morning, we crossed the river Nile and went for a game drive in Murchison Falls National Park. There were legions of bird species, hippos, giraffes and 3 of the big 5.
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| Family of warthogs wandering the camp site |
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| Red Chilli Rest Camp |
So to go back to the beginning, this weekend was my second trip out of Kampala. A group of us ventured north to Murchison Falls. The first stop on our journey was the Ziwa Rhino Sanctuary. Though rhinos were once numerous in Uganda, they had been hunted and poached to near extinction by the 1980s with the last rhino seen in the wild in Uganda in 1983. In 2004, Ziwa was established to help breed the rhinos with the hope of eventual repatriation to the wild. The sanctuary allows pretty close contact with the rhinos. It was a hot trek in the bush but so worth it.
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| Rhino trekker and a pile of rhino poop |
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Baby and Mama Rhino
|
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| Abyssinian Stork |
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| Hippos in the background |
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| Hippo footprint |
That evening there was a trip to the top of Murchison Falls. At this spot, the massive Nile River converges and pushes through a narrow gap in the surrounding rocks making powerful rapids and mist.
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| sunset at Murchison Falls |
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| Murchison Falls at a distance |
The following morning was perhaps the highlight of the trip. Entering the rainforest to trek for chimpanzees was both exciting and scary. They went about their daily business without much regard for us. They were fun to watch in their various modes of courting and play.
Tuesday 8 May 2012
Being a fashion designer vs. Being a Doctor in Uganda
A little known fact about me: when I was deciding what I wanted to do following
high school graduation, I had strongly considered applying to Parsons or FIT
with the goal of going into the fashion industry. Being practical, I decided to attend a regular
4 year college to keep my options open.
In addition to loving fashion and clothing construction, I also loved
science and knew that medicine would not be feasible with only a Parsons or FIT
background. At some point in college, I
finalized the plans to go to medical school.
I knew the training would be tough: four years of non-stop studying
followed by slaving away as an intern and resident.
Though my journey to become a physician was by no means easy
or without its challenges, I tip my hat to the Ugandan medical students and residents. Why? Because if I had to do what they do to
become a doctor and get paid the salary that Ugandan physicians get paid, you
surely would be wearing the spring line from the Sheryl Natasha House of Fashion
instead of reading a blog written by Sheryl Natasha Young, MD.
After secondary school (or the equivalent of high school in
the U.S.), the Ugandan students who qualify will enter medical school. There are some private as well as publicly
funded spots for these schools. After
medical school, they enter internship year.
One intern can be responsible for
twenty to thirty patients. An internal medicine intern training in the United
States is limited to providing ongoing care to a maximum of TEN patients.
The work of an intern involves evaluating patients, drawing
blood, inserting tubes for feeding or urinating, communicating with families
and a laundry list of other duties. This
makes for very long hours. The days off
are limited. Per one intern with whom I
recently worked, he had no days off in the preceding 7 weeks. They get paid the equivalent of $250 per month. From my
observations, the interns work and function without consistent supervision,
education, or support.
After internship year, the intern may go into general
practice in the community or return to obtain more training as a Senior House
Officer (the U.S. equivalent of a resident).
This involves working long hours supervising interns and providing care
to a large number of patients. Because
this training is seen as Master’s level program, the Senior House Officer pays
for his or her residency training. This
was astonishing to me as I could not ever fathom paying to do residency. Though I did not get paid much during
residency, the fact is that I got paid.
And my salary was sufficient for a decent standard of living.
After finishing residency, Ugandan physicians then go out
into the world to make $700 per month.
That’s less than what I made as a resident and less than what a
moonlighting hospitalist in the U.S. can make in one 12 hour shift. Many
Ugandan trained physicians will leave the country and go to places such as
Rwanda, where they can make $2000 per month.
Those that stay hold more than one job to support themselves or go into research.
The collision of a harsh training environment, brain drain,
and poor compensation results in a milieu in which patient care can get lost in
the crossfire. In realizing this, I now have a better understanding of some of the things I have seen in the hospital.
Tuesday 1 May 2012
Today Was a Good Day
Today is Labour Day in Uganda meaning that there was no laboring today. I started my day off at about 9:30 or 10 with a transfer from the bed to the couch. I enjoyed a hot breakfast which I usually don't get on the days that I work.
Around midday, trekked to the mall, had the ice cream that I had been craving for three weeks and did a bit of grocery shopping. In the afternoon I engaged in one of my favorite indulgences and got a massage at Emin Pasha (50 minutes for 50000 shillings aka $20!!). I followed this up with one of the best meals I have had since I have been here- chicken and spinach with fried plantain at a West African restaurant named Mama Ashanti.
In all of this, I racked up 4.86 miles of walking. Now I'm resting my weary legs and getting ready to go to HIV clinic tomorrow.
Around midday, trekked to the mall, had the ice cream that I had been craving for three weeks and did a bit of grocery shopping. In the afternoon I engaged in one of my favorite indulgences and got a massage at Emin Pasha (50 minutes for 50000 shillings aka $20!!). I followed this up with one of the best meals I have had since I have been here- chicken and spinach with fried plantain at a West African restaurant named Mama Ashanti.
In all of this, I racked up 4.86 miles of walking. Now I'm resting my weary legs and getting ready to go to HIV clinic tomorrow.
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