"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.