Public Health Law Map - Beta 5 - Medical and Public Health Law Site

they hospitalize or refer a patient. It is important for physicians to understand the
extent to which they may rely on students and residents to care for patients. Improper
delegation of authority to students and residents can subject attending physicians to
medical malpractice liability, license review, and criminal investigation. The case of
Libby Zion is a rare but poignant reminder of the risks of improper supervision in a
medical teaching situation. [Colford JM Jr, McPhee SJ. The ravelled sleeve of care:
managing the stresses of residency training. JAMA. 1989;261:889–893.]
Libby Zion, a young woman in generally good health, was admitted to a New York
hospital for an acute illness. She died several hours later, after questionable care from
residents who had been on duty for an extended period. A grand jury investigation
found no criminal conduct but recommended shorter hours and more supervision for
residents. [Asch DM, Parker RM. The Libby Zion case: one step forward or two steps
backward? N Engl J Med. 1988;318:771–775.]
Most private physicians do not appreciate the risks of working with an improperly
supervised teaching program. Improperly billing for work done by students or residents
may subject the physician to civil and criminal prosecution for Medicare/Medicaid
fraud. In addition, teaching programs are increasingly the target of medical malpractice
litigation and the courts have held that staff can be liable for the actions of the residents
they supervise:
[m]edical professionals may be held accountable when they undertake to care
for a patient and their actions do not meet the standard of care for such actions
as established by expert testimony. Thus, in the increasingly complex modern
delivery of medical care, a physician who undertakes to provide on- call
supervision of residents actually treating a patient may be held accountable to
that patient, if the physician negligently supervises those residents and such
negligent supervision proximately causes the patient’s injuries. [Mozingo by
Thomas v. Pitt County Mem’l. Hosp., Inc., 415 S.E.2d 341, 345 (N.C. 1992).]
1. Patients’ Rights
Physicians who work with teaching services should be careful to protect their
patients’ autonomy. Patients are entitled to control who is entrusted with their
medical care and their medical information. Ethically, a patient’s method of
payment, or the absence of payment, does not affect the right to receive care from a
licensed physician. This is also the legal rule unless modified by state law. Although
a state might pass a law conditioning the provision of charity care on the acceptance
of care by students and residents, this might pose equal protection problems under
the Constitution. If a patient who is brought into a county charity hospital that uses
students and interns extensively in first-line care demands a “real doctor,” the
hospital must produce a licensed physician to provide care. It is not acceptable to tell
the patient that no physician is available.
Patients also are entitled to know, when they first seek care from a physician,
whether they will be asked to participate in a teaching program. Private physicians
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