Patients have often commented to me that “younger doctors seem different” than the doctors that they grew up with. Without getting into the details of my patients’ perceptions, the overall sense is that younger doctors see medicine as more of a job than a calling. I would agree that there are differences and the reason for these differences can be explained by history.
This newsletter is devoted to a little-known piece of medical history that changed American medicine forever. I was a medical student in New York City on October 4, 1984, where this event occurred. Many of my professors said that this was the day that American medicine died.
The Libby Zion Case
In the fall of 1984, I started my medical training as a first-year medical student at Cornell Medical College/The New York Hospital. However, as a first year student, I was unaware of a drama that had unfolded in the hospital that night in October, which involved a young intern and a medical resident, who were just a few years ahead of me in their training.
On that fateful night, an 18-year-old woman named Libby Zion was admitted to The New York Hospital. She had a history of depression and was taking a drug called Nardil, an MAO inhibitor. Her diagnosis was not clear upon admission. The intern and resident in charge of her care had been in contact with Ms. Zion’s family physician. After admission, Libby Zion became more agitated. She was given the drug Demerol. Tragically, at that time, there was little information disseminated about a serious drug interaction between the antidepressant Nardil and the drug Demerol. As it turned out, this drug interaction proved deadly. After receiving Demerol, Miss Zion’s temperature climbed to 107 degrees, she had a cardiac arrest and she died. This was a nightmare for the family. It was devastating for the young doctors who wrote the order, and it had a paralyzing effect on this prestigious institution.
This tragedy took place before the days of computerized pharmacy systems. In fact, my class was the first in which a new computer, called the Apple, was used in medicine. At that time, doctors had to memorize everything. There were no software programs for pharmacists or physicians to check for rare drug-drug interactions, something that is now done automatically at every major hospital and drug store in the nation. Doctors simply had to memorize everything.
The legal case that followed this tragedy took on a life of its own. I began hearing about this case during my second year of medical school. Three years after I started at Cornell, as a fourth year medical student, I began to understand the greater implications of this case for my career and the future of medicine. My professors at Cornell were profoundly disturbed by how this case would ultimately change medicine. During one encounter I had with the Chief Medical Resident, he said, “This is the end of the days of medical giants.” I thought he was crazy. I thought he was overreacting. As you will soon learn, his words would turn out to be prophetic.
Cause of Death
Objectively, what caused the tragic death of Libby Zion was an arcane drug interaction between Nardil and Demerol. This drug interaction was virtually unknown by all doctors at the time, regardless of their level of training or experience. From the intern, to the resident, to the attending physician, no one knew of this drug interaction at the New York Hospital. This error was a complication of the information explosion that was occurring in medicine and the lack of a simple technology that we now have to prevent such disasters.
In the subsequent court case, which was aired on Court TV, six medical departments heads (Chiefs of Medicine at major hospitals) testified in the case. Several of these experts admitted under oath that they themselves had not heard of this drug interaction before the Zion case. These men were among the most brilliant and esteemed physicians in the country. And they had the integrity to say that they themselves could have made the same error, because no doctor can carry every piece of minutia in his brain.
Enter the Trial Lawyers
Sidney Zion, the father of Libby Zion, was a wealthy and powerful attorney. He was also a former writer for the New York Times. He insisted that his daughter had died due to overwork and a lack of supervision of these young doctors. He was seething with anger. And he did more than accuse them of medical malpractice. He went beyond the pale. Sidney Zion went public and began to refer to his daughter’s death in The New York Times as a “murder.” To be specific, murder is a legal term, defined as the unlawful premeditated killing of one human being by another.
Zion indicted the entire medical training system for his daughter’s death. Specifically, he faulted the long-hours that all medical residents worked during training. This system had been the bedrock of physician education for decades. In a NY Times editorial Zion wrote, “You don’t need kindergarten 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.” And yet, had Libby been cared for by the chiefs of medicine from the finest institutions in the land, the outcome would have been no different.
The untenable argument made by Mr. Zion was that if only an attending physician had been in the hospital, if only these young doctors had been better supervised or more rested, his daughter would still be alive.
Calls for a Murder Indictment
Pressure was placed on the District Attorney’s office. In May of 1986, the DA agreed to allow a grand jury to consider murder charges against the young doctors who cared for Libby Zion. The grand jury declined to indict the doctors for murder, but in 1987, they charged these doctors with 38 counts of gross negligence. The impact on the medical staff at Cornell was devastating. Physicians across the country watched in horror.
The Zion case was subsequently investigated by the state board of medical examiners in New York. At the end of their investigation, the board unanimously decided that none of the 38 grand jury charges against the two young residents was supported by evidence. This was not criminal negligence; it was not murder; it was an honest mistake, made by good people.
When the civil court case was finally over in 1995, the Zion family was awarded only $375,000 for their pain and suffering. The jury was not convinced that these young doctors acted out of malice, incompetence, or any other nefarious motives. But Mr. Zion was not finished. Failing to win big in the courts, he vowed to change the way that young doctors were trained across the country, and he did. He found allies in the medical world that wanted to change the way that young doctors were trained and he used his daughter’s death as a political lever to do so.
Medical Resident Work Hours
What followed was a politically-motivated investigation by the health commissioner of New York on the number of hours residents worked. 60 Minutes did a story on the Zion case, and argued that young doctors worked too many hours and did not have adequate supervision. With the Zion case as a catalyst, a commission was empanelled by the state of New York (the Bell commission) to address residents’ long work hours. The New York legislature ultimately passed a law that residents could work no longer than 24 continuous hours and could work no more than 80 hours per week. This would become known as “The Libby Zion Law.” This policy was subsequently adopted on a national level. In July of 2003 the organization that accredits all post-graduate medical training in the U.S. adopted similar restrictions for programs across the country. From 2003 onward, medical training would never be as rigorous as it had been. This was a profound shift in the training of doctors. The changes came not from medical leaders, but from lawyers and politicians with an agenda.
By comparison to the way that doctors are trained today, I worked 36 hours straight and slept in the hospital every 3rd night. I often averaged 120 hours of work per week in the hospital. My generation of physicians often trained 40 hours more per week than interns and residents of today.
The effect this case had on the training of doctors cannot be overemphasized. Doctors today see less disease during a critical point in their training than they used to. They lose continuity of care by having to leave sick patients during critical points in their illnesses. This has also changed young doctors’ attitudes about their professional identity. They no longer expect to take complete ownership of the care of their patients. They see themselves as part-of-a-team, as opposed to the professional who is primarily responsible for a human life.
What that Chief Resident was really saying to me in 1988 was that the days of medical giants was over because as physicians, we were no longer in control of our own professional destiny. From that point forward, medicine would be under the control of lawyers and politicians. How prophetic his words were indeed.
And this opinion is shared by some leading members of the legal community as well. Several years ago, I had the pleasure of sharing the speaker’s podium with the former Chief Justice of the Arizona Supreme Court, the Honorable Thomas Zlacket. After I finished speaking, Justice Zlacket pointed to me and said to the audience, “Lawyers and the insurance industry ruined this man’s profession. As lawyers, we have ruined our own profession.”