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Historical Perspective
The case that brought to public attention of the issue of resident physician work
hours is that of Libby Zion. The story is well-known to those in the medical com-
munity and impeccably outlined by Brensilver and Asch [ 18 , 19 ]. In March of 1984,
a young woman Libby Zion presented to a major New York teaching hospital with
fever and agitation. The patient’s care was provided by a team that included a resi-
dent and an intern. The patient’s clinical course was marked by increasing fever and
agitation, which ultimately ended up in cardiopulmonary arrest and death. Although
the actual cause of death was never determined, issues that became apparent during
the investigation was the lack of supervision of the resident team by the attending
physician, the delays in the patient being seen by the house staff, the use of physical
restraints, and the use of meperidine in a patient who is taking a monoamine oxidase
inhibitor (a drug-drug interaction that can cause serotonin syndrome, a likely con-
tributor to her death). Ms. Zion’s father, Sydney Zion, was a well-known New York
City attorney, former federal prosecutor, and newspaper magnate. Perhaps through
the influence of Mr. Zion, the case went to a grand jury approximately 3 years later
on criminal charges, but none were filed. There was criticism by the grand jury,
however, about the level of supervision of house staff. Following this, the New York
Department of Health initiated an investigation, but the findings were inconclusive
and only recommended censure of the involved medical providers. Subsequently,
the New York State Board of Regents again reviewed the case, and in this instance
the intern and resident were found guilty of gross negligence. The disciplinary
action imposed by the board included censure and reprimand of the residents,
however.
Following this board review, the New York City Health Commissioner formed a
commission whose task was to develop rules that would prevent similar occurrences
in the future. This committee was chaired by Dr. Bertrand Bell and was informally
known as the “Bell Commission.” Following its investigation, the Bell Commission
concluded that the Libby Zion case was marked by inadequate attending supervi-
sion and impaired house staff judgment due to fatigue, both of which contributed in
some fashion to the patient’s death. Recommendations were made for increasing
attending supervision and improved ancillary support for residents. The Bell
Commission also recommended work-hour limitations for house staff and emer-
gency room physicians. Trainees’ total weekly work schedule should be limited to
80 hours. Single shifts in the hospital should not exceed 24 hours, and emergency
room shifts should not exceed 12 hours.
These recommendations were incorporated into the New York State Health Code
by then Governor Mario Cuomo in October of 1988 and became effective in July of
- Unfortunately, the legislation laid down by the State of New York did not
result in timely compliance by many of the training programs that were affected.
For many years programs were not compliant, and because of lax enforcement by
the New York State Department of Health, these violations went unaddressed. The
impact of these regulations on resident training in New York did not go unnoticed.
In response to the potential economic impact of these regulations, it was calculated
D.J. Rea and M. Smith