The Libby Zion Case: An Exchange

To the Editors:

David Rothman’s book on doctors, Strangers At the Bedside (1991), was timely and intelligent. When I interviewed him for my recent book, The Girl Who Died Twice, I found his ideas and suggestions very helpful, and later, when my book was published, I looked forward to his opinion of it. Unfortunately for me, and for your readers, Mr. Rothman hardly mentions The Girl Who Died Twice in his recent review of it [“What Doctors Don’t Tell Us,” NYR, February 29]. Instead, he uses what he himself describes as my “thorough” account as a platform to discuss his ideas, many of which also happen to be mine, although Mr. Rothman never says so. In fact, it is difficult for the reader to know whether Mr. Rothman is discussing my ideas, my research, my conclusions, or his ideas, his research, his conclusions. This is not a departure for your publication. You rarely review books, but rather you talk at them.

Therefore, for the sake of your readers who may wish to know some details about the book Mr. Rothman talked at, let me make a brief comment, as well as two important corrections.

The Girl Who Died Twice uses the Libby Zion case to dramatize important issues concerning doctor-patient relations, hospitals, and medical education in our country. “Residency training is a wilderness that few non-physicians penetrate,” Rothman writes. This is the wilderness I penetrated and undertook to analyze. I visited and sat in on classes at six major teaching centers, including Mr. Rothman’s own, Columbia-Presbyterian. I interviewed students, interns, residents, attending doctors, administrators, and deans. I report all my findings, not one of which is mentioned by Mr. Rothman. His substantial discussion of residents covers much of the material I cover, and reaches much the same conclusions as I do. Did he make this clear to your readers? Couldn’t he have at least acknowledged the resemblance between his findings and mine? Couldn’t he have at least quoted one of my sources instead of his own? And what exactly are the “misconceptions” Mr. Rothman says I have about medical training? If “the ‘closed’ order book is not ‘the dirtiest little secret in medical education,”‘ then why does Mr. Rothman say that doctors, “for reasons of ego or embarrassment,” “generally fail to explain to patients how much of their treatment will be in the hands of residents.” Hello? Isn’t this keeping the closed order book secret? And if the closed order book is not “the dirtiest little secret,” perhaps Mr. Rothman is holding back what is the dirtiest little secret?

My hope is that after Mr. Rothman’s interesting piece, readers will want to read my book and see what it has to offer, although I must warn them that, unlike Mr. Rothman, I do not mention Foucault anywhere in it.

Now for the two corrections. Nowhere in my book do I describe Mr. Zion, as Mr. Rothman says I do, with the words “aggressive, self-centered, and self-promoting.” I sometimes dramatize situations or actions that the reader could interpret as being aggressive, self-centered, or self-promoting ones, but that is, of course, the reader’s prerogative. Mr. Rothman also says that “according to Robins [Sidney Zion’s] eulogy at his daughter’s funeral had less to say about her life than about his feelings of indignation at what her doctors had done or failed to do.” This is not what I reported of the funeral service. I stated that someone said that his eulogy “was all about Sidney…and all about how he got Libby to listen to Sinatra, and to admit that Sinatra was good…it was always about himself.” I also reported that “Sidney doesn’t recall exactly what he spoke about, but he told me he did remember that he told a story of hearing Libby listening to Billie Holiday and Bessie Smith, ‘and she said to me, “you can only go so far with rock and roll.” ‘ ”

And, I suppose, you can only go so far in trying to get a book understood. Still, a first step would be an actual review of it.

Natalie Robins

Bronx, New York

To the Editors:

I read David J. Rothman’s insightful review of the book, The Girl Who Died Twice: The Libby Zion Case and the Hidden Hazards of Hospitals with particular interest because of my expertise and continuing research and training in the field of medical education. Dr. Rothman dwells on two important issues raised in the book: the lack of attending physician supervision of residents (house staff), and the hours and intensity of work required by residents. He refers to my book Getting Rid of Patients in reference to the latter point (only). My book is based on an in-depth study of a cohort of medical residents in which I spent a year with them, and then went back to interview them five years after training.

He notes that my book has contributed to the field of medical sociology. However, I have to take issue with the comment Rothman makes that “so far as I know, Mizrahi’s book had no effect on medical training.” While my book was not written to have a direct impact on health policy related to graduate medical education, it, and my other related articles, have had a major impact in several important ways. Sometimes, however, the originators of the critical ideas and insights are not credited for their contributions. In my case, this has occurred and I would like to set the record straight.

Firstly, Natalie Robins, the author of The Girl Who Died Twice, quotes directly from an article in which I describe the way house staff handle their mistakes; I used the constructs of “denial, discounting and distancing” to characterize the range of mechanisms employed by the house staff to cope with their stressful environment. The extensive quote appears in her book on pages 224–225 without attribution. I became aware of that fact because in another review of her book published elsewhere, that reviewer referred to those concepts as if they were Robins’s own words. When I traced their usage further, I discovered that Robins was indeed quoting my words from my work, but she only referenced yet another book where my passage was first quoted, also without an accurate characterization of my study.

I point this out not only because it is important to do accurate reporting and referencing of citations, which Robins did not do, but also because these kinds of inaccuracies and omissions lead to a continuing misconception which Rothman himself conveys; namely, that academic and professional scholarship is isolated from and irrelevant in shaping policy, standards, and programs. This is far from the situation in my case.

Rothman discusses the impact that the Bell Commission had on medical reform. I would like the readers to know that indeed Dr. Bertram Bell, author of the Bell Commission report which led to changes in the NYS Regulations for Residency Training, referenced my book among a small list of works in his Commission’s report. Moreover, in personal correspondence to me directly he told me how central my book was to the Commission’s process and outcomes.

Finally, my book had an impact on the very residency program that I studied. While the name of the institution was disguised, as is common practice in sociological reporting, the chief of the Residency Training Program in Internal Medicine established a task force to restructure their program. In his written report, which apparently circulated widely, he spent three of the 25 pages discussing my book, and crediting it directly with bringing about reforms that were instituted in their program. I have a copy of the letter and the report which I am happy to share, but his name must not be used.

Clearly no one person can and should be credited for major shifts in policy, including those related to the training of physicians. However, as Rothman points out, in these times when the medical education is under attack from forces not necessarily interested in improving either the quality of medical education or practice, we need the knowledge, skill, values, and advocacy of those both inside and outside the system to make our health care system work for both the producers and consumers. It is important to understand that there is and can be a connection between theory, research, and practice.

Terry Mizrahi, MSW, Ph.D.

Hunter College School of Social Work

New York City

To the Editors:

David Rothman’s review of The Girl Who Died Twice: The Libby Zion Case and the Hidden Hazards of Hospitals by Natalie Robins raised a number of issues that continue to have pertinence. Aside from the individual tragedy of Libby Zion’s death, the most important thing that happened as a result of this sad event has been the change in house staff training and schedules. Rothman’s discussion of this complex issue touches most of the relevant points with, I think, one exception. There is the implication that attending physicians are always more competent to make decisions than are resident physicians. This seems self-evident and is the basis for discussions about “open” and “closed” order books and the degree of active participation in patient management that attending physicians should have. What is not so apparent is the fact that many attendings do not have the ability to make the meaningful decisions that are often required in acute situations. Yes, they can provide knowledge of the natural history of a disease, guide the longterm planning that is often needed, interact with the patient and family, etc., all of the qualities that are supposed to reside in the experienced, empathic physician.

But, what is the senior physician to do when confronted with the immediate problems of drug dosage, arrhythmia management, treatment of shock, etc.? The best advice is usually to get some help and the most useful help often comes from the second- and third-year residents (PGY2 and PGY3). Outside of their areas of specialization most attendings are poorly equipped to deal with a wide spectrum of problems. When I see a patient in an ICU, I would be dismayed if someone asked me to make a decision about management based on the interpretation of the dials on the respirator or the latest EKG variations. The PGY3 can often do so with ease. Learning and instruction is bidirectional in a teaching hospital and is apt to become more so as the complexity of medicine increases.

The Libby Zion case itself has a plethora of uncertainties. One of the most contentious of these is the possible interaction of the drug meperidine (Demerol) and the class of antidepressants known as MAO inhibitors. Libby Zion received both of these agents with uncertain aftereffects. I recall an informal poll of my senior colleagues at the time. None was aware of a potential problem. The current (1996) edition of Goodman and Gilman, the bible of medical therapeutics, gives minimal documentation of this reaction. Every house officer in New York, and I suspect in the country, has now heard about it, but that a PGY1 in 1984 should have known of this purported interaction seems absurd.

Polypharmacy by poly-physicians is an accelerating problem. I recently saw a patient who was taking 19 different medications prescribed by 14 different physicians. My all-time high score for totaling the number of medicine bottles in a patient’s home was 79. She wasn’t taking all of them simultaneously but used a sort of cafeteriatype approach on any given day as to what she might use. One proposed solution is via an HMO where a single physician will control referrals and attempt to monitor use of medications. The urge to treat and the demand to be treated are so pervasive, however, that the ability of one doctor to keep track of all the medications is easily overwhelmed. In addition, many patients add a long list of supplements, vitamins, herbs, minerals, etc., to their pharmacopoeia. I choose to be optimistic and think that some day patients will have computer cards containing their history and medications that could be presented to all new physicians.

Finally, white coats. Rothman comments on white coat symbolism which in some institutions has escalated into a “White Coat Ceremony.” White coats are largely an anachronism. The symbolism may seem important to the first-year medical student and probably to some patients, but in hospitals they are more likely to be a factor in the transmission of intrahospital infections. They are worn for several days before they are changed and when I look at the detritus on my own “doctor coat” after 3–4 days of wearing it, I sometimes wonder if the spirit of Ignaz Semmelweiss, who demonstrated how doctors spread puerperal fever by not washing their hands, will smite me for my carelessness. Most house officers now don’t seem to wear them. Maybe they are trying to teach the attendings something.

Joseph G. Sweeting

Professor of Clinical Medicine

College of Physicians and Surgeons

Columbia-Presbyterian Medical Center

New York City

David Rothman replies:

I regret that my review disappointed Natalie Robins, but I confess that her book disappointed me. It was not that she was afraid to take a clear position, as readers might conclude from her strained efforts here to disown her observations on Sidney Zion. Rather, she demonstrated too little subtlety or depth of understanding in her analysis of medical residency programs and such practices as the “closed order book.” Labels like “dirtiest little secret” do not capture the complexity of a residency system that is responsible for training members of house staff, or of a hospital system that puts patients “on service” or “off service.” As I pointed out, Ms. Robins “fails to recognize that the ways doctors work with house staff on behalf of private patients vary enormously.” Rather than recapitulate what I said in my review, however, let me urge readers to consider Joseph Sweeting’s remarks on the relative strengths of senior physicians and resident physicians. A comparable level of discussion is simply not to be found in Ms. Robins’s book.

I meant no disservice to Terry Mizrahi’s scholarship (and I leave it to her and Ms. Robins to resolve issues of attribution). Of course professional research has an influence on policy. But however satisfying it may be for a scholar to note a bibliographic citation or some pages of discussion in a not-to-be divulged task-force report, such references do not bring about major transformations in professional practice. To change the system of residency training required much more than that. Indeed, Mizrahi might consider the ironies of the Zion case, which showed that reforms are not necessarily the result of research and rational argument. In fact, the changes made in work schedules of residents in order to allow them more sleep came in the aftermath of an incident that actually had nothing to do with sleep deprivation.

Finally, Joseph Sweeting highlights several of the critical implications of the Zion case, including the limits of medical knowledge and the dangers of “cafeteria” medicine. It may be that new medical technology in the form of computer programs specifying drug interactions, or computer cards on patients’ prescriptions, will improve matters. But it is too early to be confident about the benefits of technology that has not been tried.