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Echoes of a “Yes”

Several months ago, I was in an appointment with “Richard.” Richard was a 45-year-old Italian-American construction worker, a father of three (four if you counted Gerald, his family’s new labradoodle puppy—which I did), and a devoted husband to his wife, Sherri, his high-school sweetheart. Unfortunately, none of these descriptors explained why he and I were in the same exam room. That was because I am a medical oncology scribe. I write notes for an oncologist. Richard was our patient: a former smoker receiving treatment for Stage IV lung cancer.

Between Richard’s hacking coughs, the doctor asked him about his symptoms. He denied fever and chills but reported shortness of breath, nausea, and vomiting. Then he chuckled, gave the doctor a rueful smile, and asked, “Does regret count?”

Of course it does, I thought to myself. Right? I paused. My fingers hovered over the keyboard. I had a decision to make. The written rule of my job is “Document what the patient says.” The unwritten rule is “Document what the patient says that is medically relevant.”

I’m supposed to judge relevance?

Clearly, I knew I should include his 60 pack-year history and his three recent failed cessation attempts. What about the feeling of overwhelming shame he described? He said it was ruining his appetite and sleep, so I included it.

But what about this next feeling? That he felt like he “deserves” this?

That he confided with a shaking voice how he hates and pities the 14-year-old Richard who found himself in a secluded corner of Golden Gate Park on a windswept summer night, with people he didn’t even like. The Richard from long ago who felt lost and alone and who made one tiny choice, who said one “yes” without understanding how that “yes” would echo for three decades, who took the cigarette he was handed and tried to light it but burned his thumb instead, who tried to pass it off with a nervous laugh, who succeeded on his second attempt to ignite the first spark of the half-million cigarattes that lit his path from Golden Gate Park to our clinic.

That feeling didn’t make it into his note. But I am grateful I get to write about it here.

Richard passed away recently, so I took another look at that note I wrote. Compared to what I was required to document, it was too long. Compared to what I wish I could have written, it will always be too short.

Brian R. Smith
Stanford, California