The Wise Men of Chelm

My local community hospital has made the leap to the 21st century by moving to computerized order entry by physicians. Like many such innovations, it gave me pause.

After nearly 30 years of practicing clinical medicine in my town, I am approaching 'gray beard' status. I am still needed, tolerated, often heard but rarely listened to. In general, I am academically toothless and pose no threat to the New World Order. I watch these innovative systems grow to the point where they are The Answer. I just don't know what the question was.

To love these systems is to love automaton thinking, multiple branch tree choices, double clicks, drop down menus, start dates and time checks, are required to order Tylenol. A blood transfusion, with its complex algorithm, means a serious investment of time to get the order in. I have made peace with this, as they tell me it cuts down on medical errors while being a more economical way to practice medicine. But why does it require an equal amount of work to cancel an order? Specifically, why do they need my reason, from a drop down menu, to explain why I am stopping a Tylenol order? They never asked me why I ordered the Tylenol in the first place.

That drop down menu requires a choice from an astonishing list of 18 reasons such as; "change in condition," "family refused," "left AMA," "duplicate order," and my all time favorite, "patient expired." So, for the last 6 months, that's the one I enter. Except when I enter the number "4" - meaning, "for ... whatever." The program accepts these entries dutifully, and without question, allowing me to proceed to discontinue the medicine with only a few more annoying double clicks.

When I was in medical school, we shared our urban campus with the dental school which offered free care in exchange for being practiced upon by clumsy students. Part of the academic model they were being taught included screening for general health problems before probing the depths of poverty stricken mouths. So, in order to gain access to their services, I had forms to fill out. Pages of forms. So I noted the bloody diarrhea that I had every morning, along with the crushing chest pain I got going up stairs, the blistering rash, the vaginal discharge, the penile discharge, and my 50 pound weight loss.

And nothing happened. The forms were collected, collated, processed and filed away. It was, for me, a teachable moment.

In pre World War II Eastern Europe, legend had it that when the Lord instructed his Angels to fly about the land distributing souls, they had two bags - one for fools and one for wise men. Flying too low over one mountain range, an Angel ripped the bottom of his bag of fools and they all tumbled out in one place, the Village of Chelm. The biggest fools became the town Elders, and so began the stories of the Wise Men of Chelm. An example of their judgment and decrees went as follows:

Before a special feasting holiday, where fried, stuffed cheese Blintzes were traditionally served with sour cream, there was no sour cream to be found. The Wise Men of Chelm, called upon to solve this crisis, ruled that henceforth all well water would be called 'sour cream,' and all sour cream would be called 'well water.' Thus, the holiday was saved.

Hospital administration is a complicated, taxing job. So many decisions, so many changes, and so much data collection. Practicing physicians, like myself, are confronted with new systems, new process, and the new world of computer based health delivery systems. Data in, data out, bits and bytes swooping and swirling about the doctor-patient relationship.

We depend upon these decision makers to provide us with the new 21st century tools needed to practice in this changing environment.

We need the Wise Administrators of Chelm to guide us in our choices.

alan berkenwald, md

(with respect to authors Sholom Aleichem and Isaac Bashevis Singer)