Psychiatrist Myron Liptzin, M.D., looked forward to his imminent retirement, believing that he would have far less stress in his life. He was wrong.
Last month the North Carolina psychiatrist lost a widely publicized lawsuit for alleged negligence in not making a specific referral before he retired for a patient with schizophrenia who later killed two people.
The suit against Liptzin, of Chapel Hill, has a startling ironic aspect in that the $500,000 malpractice verdict against him was awarded not to the families of the shooting victims, but to his former patient, who carried out the killings. A jury in an earlier capital murder trial found the patient not guilty by reason of insanity.
With his retirement from the University of North Carolina's Student Health Services imminent, Liptzin brought up the referral issue with his patient, whom he had seen for six visits. The psychiatrist explained that he did not follow through on making a specific referral because the patient said he was not sure whether he was going to return to his home, about a four-hour drive from Chapel Hill, or continue to attend law school at the university. Liptzin said he advised him to go to the local community mental health center if he returned to his small town in the mountains of western North Carolina or to seek help again from the student health service if he remained in Chapel Hill.
The patient, Wendell Williamson, had been diagnosed by Liptzin as suffering from a paranoid delusional disorder, grandiose type, and was given the antipsychotic medication thiothixene (Navane). Several weeks after Liptzin retired in May 1994, Williamson stopped taking his medication. In January 1995, Williamson walked down a busy street in Chapel Hill and opened fire, apparently randomly, killing two people and wounding a third.
Williamson, 30, was committed to Broughton State Hospital after a jury found him not guilty of the murders by reason of insanity. He is still being treated there.
He eventually decided to file a malpractice suit against his former psychiatrist, contending that if Liptzin had followed through with specific referrals or taken steps to ensure that he would continue taking his medication, the shooting spree would not have occurred. He maintained that the psychiatrist should have been aware of the danger inherent in a failure to ensure that a patient adheres, through some form of monitoring, to his medication regimen. He claimed as well that Liptzin did not adequately explain the perils of halting the medication, which had reduced Williamson's hallucinations and improved his daily functioning.
The suit was filed in May 1997. William-son has filed a similar negligence suit against the University of North Carolina, insisting that university officials failed to carry out their obligation to treat his mental illness properly, according to a report in the Raleigh News & Observer.
During the civil trial, Williamson testified that he went off the drug about four weeks after he stopped seeing the psychiatrist. Liptzin had given him a 30-day supply of medication. He stated that he had intended to stop taking it for only a few days, because he had gotten sunburned and said that either the pharmacist or Liptzin had warned him about not getting sunburned when on the drug. He also said he felt less drowsy once he stopped taking it.
Though the hallucinations returned after several weeks, Williamson did not seek additional treatment.
During the malpractice trial, Williamson, who did not take the stand in the earlier murder trial, testified that his psychiatrist deserved to shoulder most of the blame for the murders since "he had more control over the situation than I did." Under questioning by Liptzin's attorney, Bruce Berger, Williamson insisted that in fact he did not believe that he merited any blame for the shootings. He added, however, that during his therapy sessions with Liptzin, he never brought up the possibility that he would harm anyone, explaining that the idea had never occurred to him until well after he concluded his treatment with Liptzin.
At the malpractice trial, psychiatrist James Bellard, M.D., testified that Liptzin fell short of accepted standards of practice in the community by not taking more concrete steps to establish a referral. Bellard, a former trainee of Liptzin's, stated that prior to retiring, Liptzin should have arranged a meeting between himself, Williamson, and a new psychiatrist. Liptzin was also inadequately direct and firm, Bellard said, in discussions with the patient about the critical nature of continuing treatment, particularly his antipsychotic medication. He also stated that based on Williamson's symptoms, Liptzin should have immediately given him a diagnosis of schizophrenia rather than paranoid disorder, which should then have made Liptzin respond to the likelihood that the patient would not follow through with his medication regimen.
Testifying in his own defense, Liptzin maintained that he was in no way negligent in his handling of Williamson's case, and that the patient's failure to take his medication and begin treatment with another therapist should preclude any awarding of damages to Williamson. He explained as well that no therapist could have foreseen that this patient was at risk for committing violent acts. Liptzin noted that during the time he treated Williamson, he was compliant with the medical regimen and "was clearly able to understand everything I was saying to him."
Among the recommendations William-son understood, Liptzin said, was that if he did return to his hometown, his family doctor could write prescriptions for his antipsychotic medication.
Liptzin also testified that his retirement was not the sole reason that his treatment of Williamson came to an end and that the patient soon would have had to begin therapy and medication management from another clinician. The goal of the university's student health service, he noted, is not to provide long-term therapy-in fact, it is not equipped to do so. Rather, it ascertains whether a student's illness compromises his or her ability to attend classes and help students understand their illness and steps they can take to ameliorate it. He added that over the course of the six visits he had observed considerable improvement in Williamson's mental state.
As for Bellard's suggestion on the witness stand that Liptzin should have arranged a three-way meeting to begin the referral process, Liptzin told Psychiatric News that this is "nonsense in the age of managed care." He added, "Never in my experience has such a thing been done."
But the jurors didn't accept the psychiatrist's arguments. One juror, Jeryl Appleby, told the News & Observer after the verdict was rendered that in the jury's view Liptzin's "expectations of [Williamson] were unrealistic." They also believed, Appleby said, that since Williamson had begun to respond to treatment, the shooting rampage could well have been avoided had his care continued uninterrupted. "We don't have a crystal ball, so we can't say with any certainty. . . .But the likelihood would have been high," he stated.
After the verdict Liptzin commented, "I thought I had done the best I could for Mr. Williamson. I have wracked my brain looking over my care and, even knowing the awful consequences of his psychotic behavior, cannot identify anything that I would do differently."
The way the system operates, he told Psychiatric News, means that "a jury trial is about winning, not about finding the truth."
With the benefit of hindsight, he acknowledged that if he had to testify again, he would be "more humble" than he was during the September trial, rather than addressing the court in a way he characterizes as "open and demonstrable."
He pointed out, however, that he and his lawyer "were convinced that this was a case we couldn't lose. I thought if I just explained my decisions, the jury would understand how I dealt with Williamson. But they obviously didn't. All they heard was that he had a very serious illness that was missed. They saw me using a lackadaisical approach, but I used that to engage this patient, and it worked during his visits.
"My reaction to all this is akin to grieving," he emphasized. "My reactions have included shock, disbelief, followed by the realization that the dreaded has happened. . . .Just when I think I've turned the corner, something pops up."
Nor did the verdict sit well with the victims' relatives. The father of 20-year-old Kevin Reichardt, one of Williamson's targets, said he was at a loss to understand the jury's conclusion. Williamson is "a murderer who is now literally rewarded for what he did," said Karl Reichardt. "The legal system is just not doing its job in terms of justice."
The overwhelming response to the verdict from Liptzin's North Carolina colleagues has been "shock and disbelief," noted Katherine Hux, executive director of the North Carolina Psychiatric Association. "Several psychiatrists have said that in the current environment, where they are squeezed between the law, managed care, and unrealistic expectations by patients and families, it has become impossible to practice with any piece of mind."
In an era where Americans expect 100 percent success from medical treatment, she said regretfully, it is a troubling fact of life that "psychiatrists are going to be blamed when things do not turn out perfectly."
The president of the American Academy of Psychiatry and the Law, Renee Binder, M.D., cautioned psychiatrists against reading too much into the verdict against Liptzin. Lower court cases such as this one do not set legal precedent, she pointed out, appeals courts do. It does, however, illustrate that in the litigious climate pervading the U.S., "Anyone can be sued for anything." It should also put physicians on alert that no matter how solid their case may seem, "Juries do strange things. You can never be sure of the decision they will arrive at."
Psychiatrists who take the time to "go the extra mile" will gain some measure of protection should their actions ever be at issue in a malpractice suit, Binder noted. In this case, even though the patient appeared to be doing well in treatment, that meant ensuring that the patient had the name of a specific contact person who could intervene if a crisis developed or if he decided to continue with his treatment. In addition, if the patient had agreed, it would have also been prudent to inform his "support system" about steps to take if the patient had a psychiatric emergency.
Liptzin told Psychiatric News that the university, whose insurance policy will cover the award, has decided to file an appeal of the verdict. Last month the Area 5 Council, which includes the North Carolina Psychiatric Association, agreed to ask APA's Commission on Judicial Action to assess whether APA should file an amicus curiae brief to support Liptzin's appeal. If the damage award stands, the state will tap into it to pay for the care Williamson is receiving at the state hospital, a bill that is growing at the rate of $300 a day. If he remains hospitalized for several years, there may be no money left when he is discharged.