October 4, 1984 & Libby Zion: The Day Medicine Changed Forever

November 7th, 2013 By Steven Knope, MD

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 New York Hospital - Cornell CampusThe 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.

The Prophecy

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.”


5 responses to “October 4, 1984 & Libby Zion: The Day Medicine Changed Forever”

  1. Angela Zang MD writes:

    Libby Zion died March 1984, not October 1984

  2. Raj Pandya, MD writes:

    Young residents will have less experience.
    Program Directors have exploited the long hours system for long.
    Residents used to do all the scut work of blood draw, IV start, ABG , transport etc.
    Long hours did not always translate into more experience.
    Extra hours were used to be a money savings tool for hospitals.
    One slave was worth four employees.

  3. Raj Pandya, MD writes:

    There are many published articles about limits on hours in residency training. Many residency programs can eliminate paramedical work of drawing blood, starting intravenous line, doing EKG’s, drawing arterial blood samples from routine resident’s workload. This arrangement will make them more productive and provide better teaching. The hospital may have extra cost related to paramedical staff, but they should not seek exemption from established hours limit or complaint about it before taking necessary steps. Old time facility members have demonstrated resistance to any new idea and they may have undergone hardship during their own training. They want juniors to go for similar hardship. Saving money or cutting corners can be addictive for the hospital or faculty staff but the basic idea of increased hours in residency training should be increased learning and not a cost saving measure for the hospital or any self fulfilling prophecy for faculty members or program director. 80 hours is enough to learn , if residents do not have to do scut monkey work. Resident also have to read another 20-24 hours per week to make this learning interesting. I have seen a 100 million a year budget hospital reluctant to spend 25000 dollars on lab
    Technician, if residents are available to draw blood. The scut work has decreased dramatically in recent years with new generation doctors taking charge as program directors.

  4. john jaffe MD writes:

    Dr. Knope is right about the witch hunt Sidney Zion generated in search of revenge for his daughter’s death. The lethal drug-drug interaction which was the presumed cause of his daughter’s death wasn’t really widely known to ANY physicians at the time. So whether the house officers caring for Libby Zion were sleep-deprived or not, her death was mainly due to a largely unknown drug-drug interaction.

    Nonetheless, I can’t agree with Dr. Knope’s observations that somehow unnaturally long work hrs. accompanied by sleep, food, and other basic needs deprivations, is somehow necessary for good resident education. As someone who trained during the “era of the giants” (on call every other night as an intern), I recall that a large amount of that work was “scut”, and could have been done by non-medical technicians, had the hospital wanted to invest in them.

    And I often wonder how much learning indeed takes place when one is extremely fatigued, sleep-deprived, hungry, etc.? I do know there have been many studies of pilots and others who clearly make many more mistakes the more sleep-deprived they are, so it’s reasonable to assume that house officers
    working “36 hrs. straight” indeed do make many mistakes which they might not make were they adequately rested.

    So my conclusion about the Libby Zion affair and this article is: False, True, and unrelated.

  5. Kim - Pharmacist writes:

    I used to be a pharmacist at NY Hospital in the late 1980’s. The drug interaction was not “arcane”. Nardil came out in 1957. The MAOIs are and ALWAYS have been infamous for their problematic drug interactions and food restrictions. Many studies and after market reports done in the 1960’s established the serious side effects and drug interactions of MAOIs. That’s why the use of Nardil and other MAOIs PLUMMETED in the 1970’s. This is one of the first drug interactions I learned about in Pharmacy school. We learned our drug interactions before we even learned what the drugs were. Back in 1980 there was no excuse for not knowing that side effect. It doesn’t matter that there weren’t computers back then. There weren’t that many drugs on the market back then. There was no excuse for not knowing one of the 20 most deadly toxic drug/drug interactions back then. There were probably 10 drugs back then that when any of my patients were on them, I got out a reference book, looked up and double checked the interactions. MAOIs were one of those drugs. I still do that with MAOIs today

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