Future generations will attribute changes in graduate medical education to the Libby Zion case, just as the Flexner Report has been credited with altering the curriculum of undergraduate medical education. We do not question the rationale for, the need for, the effects on public safety caused by, and the educational merits of the changes produced by the Flexner Report, but I do not find much evidence that similar credit has been extended to the Zion Case. Little available work summarizes the facts, feelings, and events behind the Zion case. The Girl Who Died Twice does just that.

This is a comprehensive, fact-filled, detailed summary of and narrative about the nearly decade-long malpractice case involving the estate of Libby Zion and the New York Hospital-Cornell Medical Center. The book begins as a narrative of the weekend surrounding Zion's admission to the hospital and then weaves its way through her childhood, her family background, and her experiences at college before returning to the complex legal entanglements faced by her physicians and the New York Medical Center. Much of the background material on Zion and her family detracts from the drama and complex medicosociological concerns on which the legal issues of the case are based. Nonetheless, the reader is given a very personal look into the Zion family, and the insight gained from this look provides some explanation of the family's motivation in bringing the lawsuit.

The author does not examine in depth the effects of the lawsuit on the resident physicians who were involved. I suspect that this reflects the residents' desire not to discuss the issues with the author, but additional information about how this decade of turmoil affected their training, their career selections, and their subsequent interactions with patients would have been instructive.

Several important themes run through the book, including the importance of "physician-patient" and "physician-patient-family" communication and the roles of interns and residents within teaching hospitals. The book is long on hyperbole, containing statements such as, "Residents have their own agenda ... It's like throwing yourself into hell ..." and references to the quality of care encountered in today's teaching hospitals. There is little discussion of the merits of teaching hospitals and no discussion of the benefits of a "team approach" to health care. The author chose to focus on the potential for mistakes by resident physicians and the potential for minimal supervision by attending physicians.

Overall, this book is well written and attempts to give a balanced perspective of the issues surrounding the Zion case. The author highlights the effects the Zion case has had on graduate medical education, and the work should be required reading for every medical student in the preclinical years. It provides a sobering perspective for all who practice in teaching hospitals in the United States-attending physicians, housestaff, nurses, and administrators.

The lessons learned from the Zion case are more sociological than medical. Graduate medical education should be improved. Supervision is not a dirty word within graduate medical education. Attending physicians should play a more direct role in patient care-in the interest of both the patient and the education of housestaff. We should welcome some limits on the number of hours that resident physicians work. We should encourage residents to adopt a balanced and healthy lifestyle. We should model what we preach to our patients. We should work to eliminate sleep deprivation from the lives of all physicians. Finally, we should act with professional responsibility and creativity to address the issues of continuity of care, patient safety, and professional accountability within the framework of graduate medical education reform. I think that we in the medical community should welcome investigation and criticism of our graduate medical education system. We have the best system in the world, but it can be improved.