A Case That Shook Medicine
Tuesday, November 28, 2006
Many people have vowed to avenge the untimely death of a relative. Lawyer and journalist Sidney Zion actually did so -- to the benefit of patients and doctors-in-training nationwide.
After his 18-year-old daughter Libby died within 24 hours of an emergency hospital admission in 1984, Zion learned that her chief doctors had been medical residents covering dozens of patients and receiving relatively little supervision. His anger set in motion a series of reforms, most notably a series of work hour limitations instituted by the Accreditation Council on Graduate Medical Education (ACGME), that have revolutionized modern medical education.
Just about everyone involved in the Libby Zion case -- her father, her doctors and the people who testified at the trial that eventually resulted -- has a different account of what happened. But there are some undisputed facts.
Libby was a college freshman with an ongoing history of depression who came to New York Hospital in Manhattan on the evening of Oct. 4, 1984, with a fever, agitation and strange jerking motions of her body. She also seemed disoriented at times.
Unable to diagnose her condition definitively, the emergency room physicians admitted her for hydration and observation. As the physician of record, Raymond Sherman, a senior clinician who had treated several members of the Zion family, approved the decision by phone.
On the hospital ward where she was sent, Libby was evaluated by two residents: Luise Weinstein, an intern eight months out of medical school, and Gregg Stone, who had one additional year of training. They, too, were not quite certain of Libby's diagnosis. Stone termed it a "viral syndrome with hysterical symptoms," suggesting that Libby was overreacting to a relatively mild illness. The doctors prescribed a shot of meperidine, a painkiller and sedative, to control her shaking. Sherman approved the plan by phone.
The events of the next several hours will always remain controversial. At about 3 in the morning, Weinstein went off to care for some of the 40 other patients she was covering. Stone went to sleep in an adjacent building, where he would be available, if necessary, by beeper.
After the doctors left, Libby became more agitated. The nurses contacted Weinstein at least twice. Weinstein ordered physical restraints to hold the patient down and prevent her from hurting herself. She also prescribed an injection of haloperidol, another medication aimed at calming her down. Busy with other patients, Weinstein did not reevaluate Libby.
Libby finally fell asleep, according to the nurses, but when a nurse's aide took her temperature at 6:30 a.m., it was 107, dangerously high. Weinstein was called and emergency measures were tried to lower the temperature. But Libby Zion suffered a cardiac arrest and died. Weinstein called her parents, telling them doctors had done everything they could.
To the doctors at the hospital, the case was an inexplicable "bad outcome" in which a healthy young woman had died of a mysterious infection.
But the more Sidney Zion learned of the circumstances of Libby's death, the more he rejected this assertion. He became convinced his daughter's death was due to inadequate staffing at the teaching hospital. And he grew determined to ensure that others not fall victim to the same gaps in the teaching hospital system that he blamed for his daughter's death.
A System Under Scrutiny
First, there was a question as to whether the meperidine, known to cause fatal interactions with phenelzine -- Libby Zion's antidepressant -- had produced the high fever. Second, Sidney Zion questioned the use of restraints and shots for an increasingly agitated patient.
"They gave her a drug that was destined to kill her," Zion later stated, "then ignored her except to tie her down like a dog." To the distress of his daughter's doctors, Zion began to refer to her death as a "murder."
Zion's anger was exacerbated by what he learned about the hospital's staffing on the night Libby died. "You don't need kindergarten," he wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call -- forget about life-and-death." In addition, Weinstein, the intern assigned to Libby, was covering a large number of patients; Stone, the other resident, was never awakened; and the supervising physician, Sherman, wasn't called when Libby deteriorated.
As a columnist for the New York Daily News and a friend and confidante of many journalists and power brokers in the city, Zion vented his outrage about the state of medical education widely and loudly.
Over time, the image of the bedraggled, unsupervised intern wreaking damage in hospitals would be featured in the pages of The Washington Post, the New York Times and Newsweek. One overtired intern, interviewed on TV's "60 Minutes," obligingly forgot one of Mike Wallace's questions.
In May 1986 Manhattan District Attorney Robert Morgenthau agreed to let a grand jury consider murder charges. Although it declined to indict, the jury issued a report strongly criticizing "the supervision of interns and junior residents at a hospital in New York County."
In response, New York State Health Commissioner David Axelrod established a blue-ribbon panel of experts headed by Bertrand M. Bell, an outspoken primary care physician at the Albert Einstein College of Medicine in the Bronx, to evaluate the training and supervision of doctors in the state. Bell had long criticized the lack of supervision of physicians-in-training.
In 1989, New York state adopted the Bell Commission's recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that senior physicians needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spell their colleagues, allowing them to adhere to the new rules.
Still, some physicians resisted reform efforts. One simply could not become a qualified doctor, they argued, without experiencing firsthand what happened during the often unpredictable first 36 hours of a patient's illness. Critics attacked the night-float system, arguing that the constant trading off of patients among physicians would impede care. Many institutions essentially disregarded the new regulations.
Until 2003. In that year, the ACGME made reduced work hours mandatory for the accreditation of residency training programs across the country. The new ACGME standards look remarkably similar to those of the Bell Commission.
Now it is commonplace to see chief residents at medical centers charting the numbers of hours worked by their staffs. Residents who wish to stay longer at work are at times sent home to sleep, a development that would have been inconceivable in the past.
As might be expected, the new requirements are a work in progress. A study published in the Sept. 6, 2006, issue of the Journal of the American Medical Association found that 80 percent of interns nationwide still sometimes work excessive hours.
Data measuring whether work hour limits have improved patient care are just coming in. One study published in the New England Journal of Medicine in 2004 did find that eliminating extended work shifts improved the attention span of interns.
Historians these days tend to distrust the idea that the actions of specific people truly cause large-scale change. Rather, many argue, change more commonly results from a complex interplay of cultural and political factors.
In the case of Libby Zion, however, it is possible to trace a straight line from her death to Sidney Zion's campaign to the Bell Commission to the ACGME regulations. To be sure, it took the social changes of the 1960s and 1970s to make graduate medical education susceptible to reform from the outside. But Sidney Zion sped things up considerably, ensuring that Libby had not died in vain.
In the winter of 1994, Zion v. New York Hospital finally went to trial. Court TV avidly covered the proceedings, which were full of vitriol on both sides. In presenting its case, the hospital introduced a claim, unsupported by toxicology testing and vigorously disputed by the plaintiffs, that Libby Zion had died as a result of cocaine ingestion that she had concealed from her doctors. The jury hedged, attributing responsibility to both the doctors and the patient. Sidney Zion still calls the $375,000 jury award to him a travesty of justice.
There is one other legacy of Zion's crusade. By championing the cause of patients and families who believed they had been harmed by the medical profession, Zion helped set the stage for the medical-errors movement that began in the 1990s. To aggrieved patients and their families, Zion became a sort of folk hero.
"There is a conspiracy of silence among doctors," declared a woman from Queens in a letter to Zion. "They lie to dead patients' families." Likewise, a man who had undergone unsuccessful surgery urged Zion, "Do not give up your fight."
Throughout his crusade, Sidney Zion's anger was paramount. Indeed, it is quite possible that without this rage, he might not have accomplished what he did. Zion was "aggressive, narcissistic, self-indulgent, pushy, persistent and paranoid," psychiatrist Willard Gaylin memorably wrote in the Nation, "but that is precisely the stuff successful reformers are made of." ·
Barron H. Lerner is the Angelica Berrie-Gold Foundation Associate Professor of Medicine and Public Health at Columbia University's Mailman School of Public Health. This essay draws on his newly published book, "When Illness Goes Public: Celebrity Patients and How We Look at Medicine" (Johns Hopkins, 2006).