If It Isn’t Documented, Does It Count?

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“The quality of mercy is not strained. It droppeth as the gentle rain from heaven Upon the place beneath.”

—William Shakespeare

THESE LINES from The Merchant of Venice suggest that mercy should be freely given. However, the metrics of quality is strained, pouring like a thunderous storm obscuring visibility. As a physician standing in this downpour, I see a ray of light shining through, reminding me what matters most.

Rebecca Roy Thomas, MD, MHS

Rebecca Roy Thomas, MD, MHS

Documenting Difficult Discussions

THE DISCUSSION of fertility preservation with patients with cancer is an area that 

undeniably needs improvement for patients’ well-being and quality of life. The Quality Committee at our institution addressed this shortcoming by educating our nursing team with lectures and equipping physicians with handouts and referral sources. The initiative received tremendous positive feedback and gratitude from patients and clinicians.

As I applauded our team on the initial success, I was interrupted by a staff member who asked, “Is it documented?”—an innocent and honest question, yet one I found perplexing. Understandably, it is important to document these difficult discussions, just as we would document discussions of treatment options, prognosis, and side effects of therapy. But the follow-up remark took me aback: “If it isn’t documented, it doesn’t count.”

I remained confused as I quickly attempted to connect the teachings of my medical training to what I was being asked. Are the huge strides we made in addressing and offering reproductive options negated because the discussion wasn’t documented and a box checked off? Who should it “count” for? Did it not count for the young patients coming to grips with the news they have cancer and who now must face the possible heartbreak of not having children?

Bygone Era

MY FATHER was a general practitioner during what now seems like a bygone era when physicians had solo practices. He ran a busy clinic in the South Side of Chicago, caring for the indigent. He held Saturday morning clinics as a service to his patients rather than as a contractual obligation.

“Are the huge strides we made in addressing and offering reproductive options negated because the discussion wasn’t documented and a box checked off?”
— Rebecca Roy Thomas, MD, MHS

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Occasionally, my brother and I would accompany him. He would park his car at a nearby gas station, as there were no local parking lots or garages. Along our short walk to the clinic, he was routinely greeted by patients and family members. “Hey doc, how you doing?” “Doc, I need to bring my mom in to see you.” “I know I need to see you; I’ll come by.”

It was a time and practice that many new medical school graduates may never experience, and I am left appreciative and full of pride to have witnessed it. These were his patients, and this was his community. The trusted and genuine relationship between my father and his patients could not be checked in a box, but it counted.

Memories of India

WHEN WE were children, my siblings and I would spend our vacations visiting our relatives in India. My father would come for a week or two but no longer, since he could not leave his practice. Most of his short visit was spent with his elderly mother at their ancestral home in a small village in the southern state of Kerala.

In the 1970s, this waterlogged hamlet had no phones or TVs, and automobiles rarely passed through. The main mode of transportation was walking along the beaten roads lined by rice paddy fields. It was a different world from my suburban Chicago upbringing, yet it cradled some of my fondest memories. We would play in the warm Kerala sun learning traditional Indian games from our cousins while we taught them how to play tag and ghost in the graveyard. We woke up to the smell of coconut pancakes and ended our dinners with fried bananas sprinkled with sugar.

As a 6-year-old, I could not imagine taking time away from playing in the river, running barefoot in the sand, or trying to climb a coconut tree—for work. Yet, in his limited time away from Chicago, that is what my father did. Every morning at dawn, a line of the local poor would form outside my grandmother’s veranda waiting to see him. Many had worked for my grandparents and watched him grow up. They shared in my grandparents’ joy when he became a doctor and, in their sadness, when he left home.

“The listening ear, the healing hand, and the empathetic heart is what counts.”
— Rebecca Roy Thomas, MD, MHS

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My father would sit outside on the veranda and greet each person as they came up, one by one. There were no computers, prescription pads, privacy curtains, or exam tables. They would sit next to him as he listened to their hearts and took their blood pressures. They would talk about what was ailing them or what had transpired in their small village since he left. He offered simple remedies but more often just listened. By noon, the line would disappear, but it would resume the next morning.

On one occasion, unable to imagine spending my summers reading or doing math, I asked him why he was working when he finally had time off. Matter of factly he replied, “They have so little and are excited to see the doctor from America. If all I need to do is put up my stethoscope and take a blood pressure to give them comfort, why wouldn’t I do it?” It was a simple reply that I found absurd at the time but have reflected on many times as an oncologist.

For the thousands of underserved seeking care in an inner-city Chicago clinic, for the poor and disabled in a small backwater village, and for the numerous lives touched in between, it is not the boxes checked, the metrics measured, or dashboards reviewed that they sought. The listening ear, the healing hand, and the empathetic heart is what counts. ■

Dr. Thomas is a medical oncologist at University of Minnesota Health in Maple Grove.

DISCLOSURE: An immediate member of Dr. Thomas’ family has participated in research funded by Medtronic, Boston Scientific, and Respicardia.




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