Biggest Lesson of Intern Year

“There is no such things as an ‘otherwise healthy’ bladder cancer patient who needs a radical cystectomy.” One of my attendings and an experienced nurse practitioner shared this piece of knowledge with me while I was on the urology service. They mentioned this to me because I remarked how well all of our patients had done postoperatively after their radical cystectomies (removal of the bladder). I wondered what they meant because until then, as a bright-eyed intern, every radical cystectomy patient that I had taken care of so far had done well. That is until the readmissions started.

Three different radical cystectomy patients, operated on by three different urologists led to three readmissions in the same week. My previous string of good luck had ended. One of the three had no setbacks post-operatively and went home on post-op day 5 following the cystectomy enhanced recovery after surgery (ERAS) protocol, a standardized post-operative protocol for patients who have cystectomies  He was readmitted with urosepsis (a severe infection). One patient went home on post-op day 7 and the last patient left on post-op day 9. Before each patient was initially discharged, I had done my best to optimize their health, educate them about their condition, and prepare them for life at home without a bladder. Two of three were relatively young and had no other medical conditions besides their bladder cancer. I hadn’t expected them to come back.

My first thought when each patient was readmitted was, “Did I do something wrong?” I wondered if I had not adequately prepared them for discharge. Or, I wondered if maybe we discharged them too early. I knew the responsibility of each patient ultimately rested on my attendings, but I couldn’t help feel this way. They were my patients, too.

We learn physiology and pathology in medical school but there is still so much that we do not yet know. Physicians understand human biology and disease to a certain extent, but we don’t have as much control over the body as we would like. If we had perfect knowledge and control, taking care of patients would be much easier and there would definitely be no readmissions. This is something that I knew in theory but it didn’t truly hit home until I felt personally responsible for patients. I agonized over every detail of the three patients’ care. I helped with one of their operations and took care of each of them post-operatively. I searched for what we did wrong. I asked the rest of our team if there was anything that we could’ve done to prevent these readmissions from happening. My more experienced colleagues who had seen this plenty times reassured me – we did the best we could, these things just happen.

Things just happen and there is nothing we could do it about it. It sounds lazy and irresponsible. But I’m slowly realizing that this is a valuable lesson that I must learn in order to survive being a surgeon. I carefully observed how the different attendings handled their readmissions. There were differences in how each of them reacted, but there was one underlying theme. As much as they looked back and asked themselves what they could have done better, especially intra-operatively, they set their eyes on the next steps without getting overly fixated on the past. “These things happen, but how can I be better next time? What can we do for this patient going forward to prevent this from happening?”

I want to become a good urologist. I truly want to help patients. But it is humbling to be reminded that there are many things that we as physicians and surgeons do not have control over. We do have to be prepared for and good at the things we can control. I’m excited to learn those aspects during my residency program. But I’m learning other intangible but probably equally important lessons. I have to stay humble and remember that bad things happen and we may never find out exactly why. And I can’t let these setbacks deter me from doing the best I possibly can and learning from my mistakes. I definitely understand why they said there is no such thing as an “otherwise healthy” radical cystectomy patient. Bladder cancer is tough disease and radical cystectomies are morbid surgeries. I’ll be extra vigilant when taking care of these patients in the future. However, regardless of the patient or disease condition, I’ll remember that there are certain factors that are simply out of my control and I have to be ready to accept that.