Chelm Comes to Israel

Once upon a time, in Eastern European Jewish folklore, there was a town called Chelm, whose inhabitants were all simpletons. They tried to capture the moon, which everyone knows is made of cheese, in a barrel, and could not figure out why there seemed to be less of it each night, even though the barrel was guarded and no thief could be discovered…

There are those who think Chelm is a delightful fantasy. It's quite real, I assure you, and alive and well in Israel. (After all, if, in the Ingathering of the Exiles, we have Jews from every corner of the globe, why not Chelm?)

I work for one of the Israeli sick funds—our version of an HMO—in the Women's Clinic. And here is what happens to that yearly Pap smear your gynecologist takes:

First of course, the doctor actually gets the necessary specimen, and, after labeling it and putting it in a little plastic or cardboard holder to protect it, gives it to his nurse or office secretary, along with a computer-printed or hand written sheet that is to be given to the laboratory along with the specimen. The nurse or secretary puts both into an envelope, sealing the envelope so the "hafnaya" (the lab form) and the smear itself won't become separated from one another. Then the envelopes are either picked up by a messenger who brings it to our clinic, or the patient does, or, if the smear has been done by one of our doctors, it is given to our secretaries. If the smear is done by a doctor in another clinic belonging to our HMO, then the secretaries there deal with it, but since we are the central clinic, we get the most to process, roughly about 350-400 per month. Not infrequently, especially if the smear is taken by a doctor a long way from our central branch, it can be a week or more before it gets to us.

The medical secretary of the kupah then rips open the envelope, generates what is known as "hithayvut"—authorization (a woman gets one Pap smear a year for free, otherwise she has to pay NIS 25 per smear)—and puts the specimen, the hafnaya, and the hithayvut into ANOTHER envelope, sealing it so nothing goes astray, as before.

Then the medical secretary brings the accumulated envelopes to one of the nurses in the clinic. This is an innovation decreed by the kupah Poohbahs in Tel Aviv two years ago, supposedly for "medico-legal" reasons, but they remain completely obscure as there is no nursing input whatsoever. We merely copy, on our extremely slow and antiquated computers (doctors have Windows XP and Pentium 4 computers; we work on DOS and, if lucky, have Windows 98 and Pentium 2) what the medical secretary put onto the hithayvut page. So if there's any mistake, we just pass it right along. I won't bore you with the number of steps required for this exercise in absurdity* but between opening the envelope (usually not only sealed but stapled several times, which makes opening it without tearing the forms inside a bit tricky), paste a bar code on the hafnaya, write the patient's name (already on the specimen, remember) and ID number on another bar-coded sticker to put on the specimen container itself, and on the outside of yet another envelope, which is sealed with the two forms and specimen inside. This is tossed into a box, which waits about 3 days for another messenger who will take it to the lab. We tell patients that it will take about a month for the smear to be processed, but two weeks go by before it even gets to the lab.

So far, about four, maybe more, persons have handled the smear in its little box. Three envelopes, at least, have been used. Someone ought to do time-motion studies on this little "routine" test. It usually takes the secretaries about 5 minutes to do their thing, and anywhere between 3 and 7 minutes for the nurse—who of course is expected to take care of numerous other duties at the same time, such as antenatal followup for about 40 women a day, fetal monitors, teaching women in our high-risk clinic how to cope with their gestational diabetes and women in fertility treatment how to inject themselves, and give advice on the phone when patients call up with questions. I worked out, once, that it takes one nurse about one hour of each day just to cope with this---well, what can I call it? Exclusively secretarial task. It is a total waste of valuable nursing time, and the patient's smear results are delayed for no good reason. All doctors with the kupah are connected by computer; there is no reason, really, why the smear cannot be completely processed, including its financial authorization, at its point of origin and sent directly to the lab (which is not in Jerusalem, btw) by messenger. The current messenger makes rounds of numerous other clinics to collect specimens on a daily basis, and by next year, when the entire laboratory of the kupah nationwide is relocated to a central site, the messenger service will have to be extended anyway.

It is just stupid. For this I went to nursing school for 4 years. To put bar codes on lab specimens and to unstaple envelopes. Bah humbug.

*Well, if you must know the computer steps involved, they are as follows:
Main menu → sub menu → patient's ID # → code for Pap smear → doctor's name or code # → note if patient teaching done (y/n) → write in "Pap sent to lab" → note whether this is a work accident (y/n) → then press, in sequence: F10, F3, 3, F6, F7, fill in password, type of exam (code), Dr's ID code, date, bar code number. Press Enter three times then F12.

Then go back to the beginning and do it all over again with the next specimen. Assuming the computer doesn't crash, which it often does.