Book Review

The Girl Who Died Twice: Every patient's nightmare: The Libby Zion case and the hidden hazards of hospitals

N Engl J Med 1996; 334:201-202January 18, 1996

Article

The Girl Who Died Twice: Every patient's nightmare: The Libby Zion case and the hidden hazards of hospitals
By Natalie Robins. 332 pp. New York, Delacorte Press, 1995. $22.95. ISBN: 0-385-30809-4

Natalie Robins tells the story of an 18-year-old woman who died 11 years ago while under the care of residents at New York Hospital and of her father's crusade to blame the medical-education system. Sidney Zion's efforts ultimately led to the New York State Department of Health's “405 Regulations,” which recommended limiting the working hours of house staff and increasing supervision by attending physicians. Robins paints a not altogether sympathetic picture of Sidney Zion's mission, which seems at times obsessive, vengeful, and self-serving, but she joins him in denouncing graduate medical education for giving residents too much independence.

The author has been thorough in her investigation, but what her book boasts in detail it lacks in analysis. The barrage of facts can be overwhelming, especially when different sources give contradictory accounts of the same events, and it doesn't help that the book lacks structure and chapter titles.

For interpretation, the author's hands are tied in one important respect: she is not a clinician. The opinions of several experts are scattered throughout — Libby died of toxic shock syndrome, an adverse drug interaction, cocaine toxicity, or severe bronchitis — but the question remains: What killed Libby Zion? The answer is important, because the book implies that, in large part, the system of medical education killed Libby Zion. A clinician might better have assessed whether the residents involved in Libby's care deviated from acceptable standards and whether the presence of an attending physician at Libby's bedside would have made a difference.

Even so, Robins lands squarely on a most interesting question: How can we balance the need of young physicians to assume responsibility for patients against the need of patients to have experienced doctors? In other words, are house staff adequately supervised by attending physicians?

As a third-year medical student in my sixth month of clinical training, I must confess that Robins's book unearthed my deepest fears. I found myself alternating between two extremes: a panicked conviction that Robins was right about the inadequate supervision of house staff and students and an impulse to defend the competence of house staff.

I have been amazed by the degree to which patients are cared for by house staff, and the scarcity of attending physicians. Before I began my rotations, I envisioned swarms of formidable, gray-haired attending physicians at the bedside, lecturing the house staff wisely on the subtleties of diagnosis and management and mercilessly grilling the medical students. Something like this does happen, but only briefly. There is little time for questions, for a review of physical findings, or even for every team member's hovering stethoscope to land. Rounds often serve as the attending physician's only visit to the patient that day, and teaching is secondary to the practical matter of completing a rapid physical examination. (For this reason, the time spent “teaching” calculated by Shea et al. elsewhere in this issue of the Journal may be overestimated, as Kassirer points out in his editorial, since it in some measure doubles as “clinical” time.) The bulk of the teaching of interns and medical students is actually done by senior house officers, in brief conversations in the halls, and primarily by example.

I have been surprised and sometimes alarmed by the lack of involvement of attending physicians in teaching and patient care, yet I hesitate to say that their supervision is inadequate. I do not have enough clinical experience to know whether a lack of supervision by attending physicians compromises patient care. Neither does Robins. Nevertheless, her argument that house staff are inadequately supervised is hyperbolic and self-assured. She tells us that medical students are called “animals” by the house staff when they become confident in performing new procedures and eager to practice their new-found skills. “Such animals are roaming American hospitals caring for patients,” she concludes ominously.

Robins is particularly incensed by what she calls the “closed order book,” meaning the book (or computer program) in which orders are written, largely by residents. This to her embodies the lack of supervision in teaching hospitals. “Closed order book” is a phrase I have never heard, and Robins does not specify where she came by the term. She refers to the order book as “the big sin. . . . when unpracticed interns and residents write orders, a protocol that discourages them from asking for help on anything else related to their patients' care and well-being.” To her, it is “the best-kept secret in hospitals, and the dirtiest little secret in medical education . . . a trade secret so dark that many doctors I interviewed said they hadn't ever heard the term used.” The closed order book surfaces again and again throughout The Girl Who Died Twice. Robins's attention to this term, which is not widely used among physician and which represents a practice so standard and openly accepted in hospitals, seems a poor substitute for intelligent discussion of the supervision of house staff.

But Robins does raise interesting points. She points out that Libby Zion's several cross-reacting prescription drugs, the effects of which probably contributed to her death, might have been avoided if she had had coordinated care. And she suggests that the degree to which house staff take responsibility for patients without direct supervision is in part secondary to “the new realities of medicine — sicker and poorer patients, increased service needs, staff deficiencies, insurance and other financial concerns.” House staff probably are assuming, disproportionately, additional work as diagnostic and management options become more numerous and the interaction with patients is condensed into shorter hospital stays. In my opinion, the single greatest pressure to discharge patients quickly is not from hospital administrators, insurers, or attending physicians, but from house staff's need to keep the patient load manageable. During my medicine rotation one intern admitted 13 new patients in one night; her incentive to discharge patients the next day must have been great. Robins cites a term coined by Dr. David Hilfiker in his book Healing the Wounds: A Physician Looks at His Work (New York: Penguin Books, 1987): a “failure of will,” meaning a failure to do the best thing for a patient simply because of distraction or exhaustion. Such failures of will — however inconsequential — must happen all the time.

The Girl Who Died Twice is a thorough recounting of the Libby Zion story, and it raises interesting questions about medical education in hospitals. But its fatal flaw is that the author does not have the clinical background to make a convincing case that house staff are inadequately supervised. Instead, she falls back on an inflammatory style that taps into the fears of a distrustful public. I hope her readers remember that residents are doctors who have already completed medical school and received their professional degrees. Perhaps in no other profession are certified professionals so closely supervised by their older colleagues. House staff are enormously bright and well-trained people with a powerful work ethic, dedication to patient care, and desire to exceed expectations. They are given a job too big to do, and yet they do it — by knowing when to ask questions, and by working themselves to the bone. From my front-row seat, they look like the hospital's hidden heroes rather than its hidden hazards.

Lara Goitein
Harvard Medical School, Boston, MA 02115

Citing Articles (1)

Citing Articles

1. 1

   Kassirer, Jerome P., . (1996) Tribulations and Rewards of Academic Medicine — Where Does Teaching Fit?. New England Journal of Medicine 334:3, 184-185
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