Case Title: Sullivan v. Edward Hospital

Citation: 

Docket Number: 95409

State: illinois

Court: Illinois Supreme Court

Date: 2004-02-05T00:00:00Z

Document:
Docket No. 95409-Agenda 9-November 2003.
JUANITA SULLIVAN, Indiv. and as Special Adm'r of the Estate of
Burns Sullivan, Deceased, Appellant, v. EDWARD HOSPITAL et al., 							Appellees.
Opinion filed February 5, 2004. 
	JUSTICE FREEMAN delivered the opinion of the court:
	Plaintiff, Juanita Sullivan, individually and as special administrator of
the estate of Burns Sullivan (Burns), brought a medical malpractice action
in the circuit court of Du Page County. Plaintiff named as defendants
Edward Hospital (the hospital) and Dr. Amelia Conte-Russian. Plaintiff
claimed that the hospital, through one of its nurses, and Dr. Conte-Russian
were negligent in the care and treatment of Burns. The trial court entered
a directed verdict for the hospital after plaintiff's only medical expert was
ruled incompetent to testify as to the standard of care for the nursing
profession. The trial court subsequently entered judgment on a jury verdict
in favor of Dr. Conte-Russian.
	The appellate court affirmed. 335 Ill. App. 3d 265. We allowed
plaintiff's petition for leave to appeal (177 Ill. 2d R. 315(a)), and now
affirm the appellate court.

BACKGROUND
	The record reveals the following pertinent facts. In March 1995,
Burns suffered a second stroke, which resulted in partial paralysis to his
right side, impairing his ability to walk independently. Also as a result of
the stroke, Burns could not speak, but could understand others and
respond with physical gestures. Since March 1995, Dr. Conte-Russian,
a general internist, had been Burns' regular treating physician.
	On November 1, 1997, Burns, then 74 years old, was admitted to
the hospital for treatment of a urinary tract infection. While at the hospital,
Dr. Conte-Russian was Burns' primary care physician. The hospital
categorized a patient's risk of falling between two levels. A patient who
has no impairments of any kind is characterized as a level I fall risk. A
patient who has any physical or mental impairments that increase the risk
of falling is characterized as level II. Because of Burns' history of partial
paralysis, he was characterized as level II.
	On the evening of November 2, 1997, nurse Carrie Lewis was
Burns' primary nurse. Burns had been in his bed, equipped with four side
rails, all of which were raised. Between 7 p.m. and 9:30 p.m., nurse Lewis
went into Burns' room and found Burns attempting to get out of bed
through the side rails. After each of the first two occurrences, nurse Lewis
found Burns to be alert, oriented, and able to understand her instructions
to stay in bed. After the third occasion, Burns still appeared alert and
oriented. However, nurse Lewis became concerned because of Burns'
failure to follow instructions and because Burns now appeared to be
agitated. Nurse Lewis was concerned that Burns might again attempt to
get out of bed and that he could fall if he did so.
	Based on these concerns, nurse Lewis telephoned Dr. Conte-Russian
at approximately 9:30 p.m. and asked the doctor to order a "posey vest"
to restrain Burns to his bed. A posey vest is used to restrain a patient by
placing the vest on the patient and then tying the vest straps to the bed. Dr.
Conte-Russian advised nurse Lewis that a posey vest might result in Burns
becoming even more agitated. Rather than using a physical restraint, Dr.
Conte-Russian ordered the administration of the drug Ativan to calm
Burns and help him sleep. Dr. Conte-Russian prescribed a very small
dosage and left it to nurse Lewis' discretion to administer more Ativan if
needed.
	At approximately 10 p.m., nurse Lewis administered to Burns one
milligram of Ativan, which was expected to last for at least two hours.
Between 10 p.m. and midnight, nurse Lewis and a nurse's aide checked
on Burns approximately every half hour. By 10:30 p.m. Burns was asleep;
he was sleeping at each half-hour check. At approximately 12:05 a.m., a
nurse's aide walked past Burns' room and looked inside; Burns appeared
to be sleeping. At 12:10 a.m., a monitor technician heard a noise in the
area of Burns' room and so informed nurse Lewis. Upon receiving this
report, nurse Lewis ran to Burns' room and found him on the floor with
his head bleeding from a cut above his left eye. Apparently, Burns had
attempted to get up from his bed and walk; however, he fell and struck his
head on the hospital room floor. As a result of the fall, Burns developed
a subdural hematoma, for which he received treatment. At the request of
his family, Burns was subsequently transferred to another hospital.
	On November 6, 1998, plaintiff and Burns filed a two-count
complaint against the hospital and Dr. Conte-Russian. The complaint
alleged that the hospital, through nurse Lewis, and Dr. Conte-Russian,
failed to properly monitor, medicate, or restrain Burns. In count I, Burns
sought damages for injuries proximately caused by defendants' negligence.
In count II, plaintiff sought damages for loss of consortium. In September
1999, Burns died of a third stroke, which was unrelated to plaintiff's
allegations of negligence. On December 28, 1999, Burns' death was
formally reported to the trial court; plaintiff was appointed special
administrator of Burns' estate and substituted as the sole plaintiff.
	At trial, plaintiff attempted to establish the hospital's liability
vicariously through the actions of nurse Lewis. Plaintiff called Dr. William
Barnhart to testify as her medical expert. Dr. Barnhart is a board-certified
physician specializing in internal medicine and has substantial experience
in observing and working with physicians and nurses in the area of patient
fall protection. Plaintiff intended for Dr. Barnhart to testify to the
applicable standards of care for physicians and nurses, and the failure of
both Dr. Conte-Russian and nurse Lewis to meet their respective
standards of care.
	Dr. Barnhart testified as to the standard of care for a licensed nurse
and the instances in which nurse Lewis deviated from the standard of care.
According to Dr. Barnhart, one such instance included nurse Lewis'
failure to properly communicate Burns' condition to Dr. Conte-Russian
during their phone conversation. The trial court found that plaintiff did not
properly disclose Dr. Barnhart's opinion on this issue during pretrial
discovery, in violation of Supreme Court Rule 213(g) (177 Ill. 2d R.
213(g)). Therefore, the trial court struck the testimony relating to nurse
Lewis' communications with Dr. Conte-Russian.
	According to Dr. Barnhart, nurse Lewis deviated from the standard
of care for a licensed nurse also by her failure to adhere to proper nursing
procedures in the care and treatment of a patient. Dr. Barnhart opined that
nurse Lewis, after having failed to receive Dr. Conte-Russian's approval
to use a posey vest on Burns, should have gone up the nursing chain of
command to pursue her concerns that Burns would attempt to get out of
bed; that she should have provided for an alternative to the posey vest to
protect against the risk of a fall; and that nurse Lewis should have had a
sitter in Burns' room, or should have moved Burns' bed to an area where
Burns could have received constant supervision. At the close of plaintiff's
case, the trial court struck this testimony on the grounds that a physician
is incompetent to testify to the standard of care placed upon a licensed
nurse.
	Dr. Barnhart was plaintiff's only medical expert as to the standard of
care for the nursing profession. After the trial court ruled that Dr. Barnhart
was incompetent to testify as to that standard, the court granted the
hospital's motion for a directed verdict. Thereafter, the jury returned a
verdict in favor of Dr. Conte-Russian and the trial court entered judgment
thereon. The appellate court affirmed. 335 Ill. App. 3d 265.
	This court allowed plaintiff's petition for leave to appeal. 177 Ill. 2d
R. 315(a). We subsequently granted the Illinois Trial Lawyers Association
leave to submit an amicus curiae brief in support of plaintiff. We also
granted the American Association of Nurse Attorneys leave to submit an
amicus curiae brief in support of the hospital. 155 Ill. 2d R. 345. We will
refer to additional pertinent facts as they relate to the issues plaintiff raises
before this court.

ANALYSIS
I. Dr. Barnhart's Testimony
	Plaintiff contends that the trial court erred in striking, as a discovery
sanction, Dr. Barnhart's testimony relating to nurse Lewis'
communications with Dr. Conte-Russian. Plaintiff also contends that the
trial court erred in striking Dr. Barnhart's testimony relating to the standard
of care for the nursing profession and, consequently, entering a directed
verdict in favor of the hospital.

A. Discovery Violation
	During pretrial discovery, plaintiff submitted a disclosure pursuant to
Supreme Court Rule 213 (177 Ill. 2d R. 213), which disclosed the names
and addresses of plaintiff's witnesses and "the subject of their testimony."
This disclosure included Dr. Barnhart's name and address, and the
following description of his anticipated testimony:
			"It is anticipated that Dr. Barnhart will testify that it is his
opinion that Dr. Conte[-]Russian and Edward Hospital deviated
from the accepted standards of medical care by disregarding Mr.
Burns Sullivan's status as a level II fall risk suffered from
cognitive impairment and inability to understand directions and
was found trying to climb out of bed on three prior occasions
even though he suffered from Hemi-paralysis. He will testify that
Dr. Conte-Russian and the Edward Hospital staff should have
restrained Mr. Sullivan in bed so that he could not get out.
Further, he will testify that the attempt to sedate Mr. Sullivan by
issuing medication as opposed to restraints was not properly
performed. He will also testify that it is his opinion that Mr.
Sullivan was not properly monitored during sedation despite his
inability to understand direction and physical impairments. He will
also testify that in his opinion Mr. Burns Sullivan's injuries were
sustained as a result of medical negligence.
			Dr. Barnhart will testify that in his opinion, Dr. Conte-Russian,
after having been advised of Mr. Sullivan's three prior attempts
to get out of bed and remove his IV[,] should have ordered
restraints for Mr. Sullivan. He will testify that in his opinion Dr.
Conte-Russian and the Edward Hospital medical staff should
have ordered restraints for Mr. Sullivan. That in his opinion, Dr.
Conte-Russian and the Edward Hospital medical staff should
have monitored Mr. Sullivan more frequently after the decision
not to use restraints was made. That as a result of Dr. Conte-Russian's decision not to properly restrain Mr. Sullivan, he fell
out of bed and sustained brain injury including a subdural
hematoma."
At trial, Dr. Barnhart's testimony reflected this disclosure. However, he
also testified that one instance where nurse Lewis deviated from the
standard of care for professional nurses was her failure to adequately
communicate Burns' condition to Dr. Conte-Russian during their phone
conversation.
	At the close of Dr. Barnhart's testimony, the hospital moved to strike
that portion of his testimony relating to nurse Lewis' communication of
Burns' condition to Dr. Conte-Russian. Plaintiff conceded that Dr.
Barnhart's specific opinion regarding nurse Lewis' failure to adequately
communicate with Dr. Conte-Russian was not included in plaintiff's Rule
213 disclosure. The trial court granted the hospital's motion to strike this
testimony.
	This cause was tried prior to the amendment of Rule 213 effective
July 1, 2002, so we will refer to its preamendment version. Supreme
Court Rule 213(g) requires that, upon written interrogatory, a party must
disclose the subject matter, conclusions, opinions, qualifications, and all
reports of a witness who will offer any opinion testimony. 177 Ill. 2d R.
213(g). Further, Supreme Court Rule 213(i) imposes on each party a
continuing duty to inform the opponent of new or additional information
whenever such information becomes known to the party. 177 Ill. 2d R.
213(i). The Rule 213 disclosure requirements are mandatory and subject
to strict compliance by the parties. Seef v. Ingalls Memorial Hospital,
311 Ill. App. 3d 7, 21 (1999); Warrender v. Millsop, 304 Ill. App. 3d
260, 265 (1999). The admission of evidence pursuant to Rule 213 is
within the sound discretion of the trial court, and the court's ruling will not
be disturbed absent an abuse of that discretion. Susnis v. Radfar, 317 Ill.
App. 3d 817, 828 (2000); Seef, 311 Ill. App. 3d at 22.
	As noted, plaintiff concedes that Dr. Barnhart's specific opinion
regarding nurse Lewis' failure to adequately communicate Burns'
condition to Dr. Conte-Russian was not included in plaintiff's Rule 213
disclosure. However, plaintiff argues that the "gist" of Dr. Barnhart's trial
testimony regarding nurse Lewis' telephone conversation with Dr. Conte-Russian was an "elaboration" or a "logical corollary" of, or "effectively"
implicated, plaintiff's Rule 213 disclosure.
	The trial court did not accept this argument, and neither do we. As
the trial court reasoned, "you have to drop down to specifics." Rule 213
permits litigants to rely on the disclosed opinions of opposing experts and
to construct their trial strategy accordingly. Firstar Bank of Illinois v.
Peirce, 306 Ill. App. 3d 525, 532 (1999). The supreme court rules
represent this court's best efforts to manage the complex and important
process of discovery. One of the purposes of Rule 213 is to avoid
surprise. 177 Ill. 2d R. 213(g), Committee Comments. To allow either
side to ignore Rule 213's plain language defeats its purpose and
encourages tactical gamesmanship. Department of Transportation v.
Crull, 294 Ill. App. 3d 531, 537 (1998). Our appellate court has stated:
		" 'Rule 213 establishes more exacting standards regarding
disclosure than did Supreme Court Rule 220 ***, which
formerly governed expert witnesses. Trial courts should be more
reluctant under Rule 213 than they were under former Rule 220
(1) to permit the parties to deviate from the strict disclosure
requirements, or (2) not to impose severe sanctions when such
deviations occur. Indeed, we believe one of the reasons for new
Rule 213 was the need to require stricter adherence to disclosure
requirements.' " Susnis, 317 Ill. App. 3d at 828-29, quoting
Crull, 294 Ill. App. 3d at 538-39.
We agree. Given this stricter standard of compliance, we hold that the trial
court did not abuse its discretion in finding that plaintiff violated Rule
213(g). See Susnis, 317 Ill. App. 3d at 829.
	Plaintiff further argues that even if Dr. Barnhart's testimony
constituted a discovery violation, the extreme remedy of striking the
testimony constituted an abuse of the trial court's discretion. We disagree.
" 'Where a party fails to comply with the provisions of Rule 213, a court
should not hesitate sanctioning the party, as Rule 213 demands strict
compliance.' " Peirce, 306 Ill. App. 3d at 533, quoting Warrender, 304
Ill. App. 3d at 268. In determining whether the exclusion of a witness is
a proper sanction for nondisclosure, a court must consider the following
factors: (1) the surprise to the adverse party; (2) the prejudicial effect of
the testimony; (3) the nature of the testimony; (4) the diligence of the
adverse party; (5) the timely objection to the testimony; and (6) the good
faith of the party calling the witness. The decision whether or not to
impose sanctions lies within the sound discretion of the trial court, and that
decision will not be reversed absent an abuse of discretion. Warrender,
304 Ill. App. 3d at 268; Ashpole v. Brunswick Bowling & Billiards
Corp., 297 Ill. App. 3d 725, 727 (1998).
	The record shows that, regarding the first factor, the hospital was
clearly surprised by Dr. Barnhart's testimony. Plaintiff concedes that the
Rule 213(g) disclosure did not contain the opinion to which Dr. Barnhart
testified. Further, nowhere in his deposition does Dr. Barnhart suggest or
imply that nurse Lewis failed to communicate appropriately with Dr.
Conte-Russian and that this failure proximately caused Burns' fall.
	Regarding the second and third factors, the nature of the testimony
and its prejudicial effect are manifest. Dr. Barnhart testified regarding an
instance of how the hospital deviated from the standard of care for nurses.
This was a theory of negligence of which the hospital should have been
informed. Regarding the fourth through the sixth factors, the record shows
that the hospital was diligent in sending its Rule 213 interrogatories to
plaintiff; that the hospital timely objected to the contested testimony; and
that this lapse in an otherwise detailed summary of Dr. Barnhart's
anticipated testimony does not indicate good faith.
	The purpose behind Rule 213 is to avoid surprise and to discourage
tactical gamesmanship. "Rule 213 brings to a trial a degree of certainty
and predictability that furthers the administration of justice. The rule should
be enforced by trial judges." Peirce, 306 Ill. App. 3d at 536. We cannot
say that the trial court abused its discretion in striking this portion of Dr.
Barnhart's testimony. See Susnis, 317 Ill. App. 3d at 829 (finding no
abuse of discretion when trial court bars expert physician testimony after
party fails to make Rule 213 disclosure of testimony regarding the relevant
standard of care).

B. Nursing Standard of Care
	Plaintiff also contends that the trial court erred in striking Dr.
Barnhart's testimony relating to the standard of care for the nursing
profession and, consequently, entering a directed verdict in favor of the
hospital. "In directing a verdict, the trial court determines as a matter of
law that there are no evidentiary facts out of which the jury may construe
the necessary fact essential to recovery." (Emphasis added.) Jones v.
O'Young, 154 Ill. 2d 39, 47 (1992). Accordingly, our review is de novo.
	This court has explained the requirement of expert medical testimony
in a medical malpractice action as follows:
			"In a negligence medical malpractice case, the burden is on
the plaintiff to prove the following elements of a cause of action:
the proper standard of care against which the defendant
physician's conduct is measured; an unskilled or negligent failure
to comply with the applicable standard; and a resulting injury
proximately caused by the physician's want of skill or care.
[Citations.] Unless the physician's negligence is so grossly
apparent or the treatment so common as to be within the
everyday knowledge of a layperson, expert medical testimony is
required to establish the standard of care and the defendant
physician's deviation from that standard." Purtill v. Hess, 111 Ill. 2d 229, 241-42 (1986).
Accord Dolan v. Galluzzo, 77 Ill. 2d 279, 282 (1979).
	In this case, the trial court ruled that Dr. Barnhart was incompetent
to testify as to the standard of care for the nursing profession and nurse
Lewis' deviations therefrom. The appellate court upheld the trial court's
ruling. 335 Ill. App. 3d at 269-72. In Jones, 154 Ill. 2d  at 43, this court
summarized the test of an expert physician's competency to testify:
			"In Purtill v. Hess (1986), 111 Ill. 2d 229, this court
articulated the requirements necessary to demonstrate an expert
physician's qualifications and competency to testify. First, the
physician must be a licensed member of the school of medicine
about which he proposes to testify. (Purtill, 111 Ill. 2d  at 242-43, citing Dolan v. Galluzzo (1979), 77 Ill. 2d 279.) Second,
'the expert witness must show that he is familiar with the
methods, procedures, and treatments ordinarily observed by
other physicians, in either the defendant physician's community
or a similar community.' (Purtill, 111 Ill. 2d  at 243.) Once the
foundational requirements have been met, the trial court has the
discretion to determine whether a physician is qualified and
competent to state his opinion as an expert regarding the
standard of care. Purtill, 111 Ill. 2d  at 243."
If the expert physician fails to satisfy either of these foundational
requirements, "the trial court must disallow the expert's testimony." Jones,
154 Ill. 2d  at 44.
	Dolan established the first requirement, i.e., that a health-care expert
witness must be a licensed member of the school of medicine about which
the expert proposes to testify. Dolan explained that there are different
systems or schools of medicine with varying tenets and practices, and that
testing the care and skill of a practitioner of one school of medicine by the
opinion of a practitioner of another school would result in inequities. The
practitioner of a particular school of medicine is entitled to have his or her
conduct tested by the standards of that school. Dolan, 77 Ill. 2d  at 283
(and authorities cited therein).
	This court in Dolan further observed:
			"Illinois statutes [citations] provide for the regulation of
practitioners of medicine and surgery, physical therapy, nursing,
pharmacy, dental surgery, podiatry, optometry, etc. This is a
clear expression by the legislature of public policy to recognize
and regulate various schools of medicine. The various acts
regulating the health professions [citations] provide for different
training, and regulate the treatment each profession may offer.
*** We simply are not disposed to provide for what, in effect,
may result in a higher standard of care when the legislature, by
recognizing various schools of medicine, has not done so. To do
so would not only be unfair *** , but it would also assume that
science and medicine have achieved a universal standard of
treatment of disease or injury. Such is not the case. In its
wisdom, the legislature has recognized a fundamental tenet of
contemporary life: no one person, group or school has yet
succeeded in abstracting a universal medical method from the
many changing methods used in science and medicine." Dolan,
77 Ill. 2d  at 284.
Accordingly, the Dolan court held that "in order to testify as an expert on
the standard of care in a given school of medicine, the witness must be
licensed therein." Dolan, 77 Ill. 2d  at 285.
	Plaintiff argues that Illinois law no longer holds that a health
professional expert witness must always be a licensed member of the
school of medicine about which the expert proposes to testify. In support
of her argument, plaintiff cites the following from Jones:
			"By hearing evidence on the expert's qualifications and
comparing the medical problem and the type of treatment in the
case to the experience and background of the expert, the trial
court can evaluate whether the witness has demonstrated a
sufficient familiarity with the standard of care practiced in the
case. The foundational requirements provide the trial court with
the information necessary to determine whether an expert has
expertise in dealing with the plaintiff's medical problem and
treatment. Whether the expert is qualified to testify is not
dependent on whether he is a member of the same specialty
or subspecialty as the defendant but, rather, whether the
allegations of negligence concern matters within his
knowledge and observation." (Emphasis added.) Jones, 154 Ill. 2d  at 43.
Based on the italicized sentence, plaintiff argues that Jones "retreats from
any rigid, formalistic rule" that a health professional expert witness must be
a licensed member of the school of medicine about which the expert
proposes to testify.
	We cannot accept this argument. Jones clearly reaffirms this court's
decision in Purtill describing two foundational requirements: that the
health-care expert witness must be a licensed member of the school of
medicine about which the expert proposes to testify; and that the expert
must be familiar with the methods, procedures, and treatments ordinarily
observed by other health-care providers in either the defendant's
community or a similar community. Indeed, the very next sentences in
Jones following the italicized sentence upon which plaintiff relies state: "If
the plaintiff fails to satisfy either of the foundational requirements of Purtill,
the trial court must disallow the expert's testimony. (Purtill, 111 Ill. 2d  at
244.) The requirements are a threshold beneath which the plaintiff cannot
fall without failing to sustain the allegations of his complaint." Jones, 154 Ill. 2d  at 44. It is only after determining that both foundational
requirements are satisfied that the court proceeds to evaluate whether the
allegations of negligence concern matters within the expert's knowledge
and observation. Instead of retreating from the license requirement, Jones
clearly reaffirms that a plaintiff must satisfy both requirements. Jones, 154 Ill. 2d  at 44, citing Purtill, 111 Ill. 2d  at 244.
	Plaintiff similarly points to language in Gill v. Foster, 157 Ill. 2d 304
(1993), in arguing that Dr. Barnhart's lack of licensure in the nursing
profession should have gone only to the weight of his testimony and not its
admissibility. Plaintiff misreads Gill. In that case, the trial court barred the
plaintiff's expert, a licensed general surgeon, from testifying that the
defendant, a licensed radiologist, deviated from the standard of care. Gill,
157 Ill. 2d  at 315-16. The plaintiff in Gill argued that his expert was
licensed to practice medicine in all of its branches and, therefore, the
expert's testimony should have been admitted, with his qualifications going
to the weight of his opinion. This court agreed with the plaintiff; however,
only after finding that the plaintiff had satisfied the licensing requirement.
Gill, 157 Ill. 2d  at 317. We cited to Purtill for its three-step analysis: the
two foundational requirements of licensure and familiarity, and the
discretionary requirement of competency. Gill, 157 Ill. 2d  at 316-17.
When this court ruled that the plaintiff's expert could testify, it was in the
context of the trial court's discretion to determine whether the physician
was qualified and competent to state his opinion regarding the standard of
care. Gill, 157 Ill. 2d  at 317. This court was not discussing whether the
plaintiff's expert satisfied the licensing requirement. Far from overruling
Dolan and its progeny, Gill expressly upheld Purtill's three-step analysis.
Clearly, Gill and Jones do not stand for the proposition that this court has
disregarded, or should disregard, the licensing requirement first established
in Dolan.
	Plaintiff next contends that the appellate court failed to consider
section 2-622 of the Code of Civil Procedure (735 ILCS 5/2-622 (West
2000)), enacted in 1985, subsequent to Dolan. Section 2-622 provides
that in any medical malpractice action, the plaintiff's attorney must attach
to the complaint an affidavit stating that the plaintiff has consulted with a
health professional in whose opinion there is a "reasonable and meritorious
cause" for the filing of the action. The plaintiff must file a written report,
attached to the affidavit, prepared by that health professional indicating the
basis for his determination. The section specifically provides:
		"If the affidavit is filed as to a defendant who is a physician
licensed to treat human ailments without the use of drugs or
medicines and without operative surgery, a dentist, a podiatrist,
or a psychologist, or a naprapath, the written report must be
from a health professional licensed in the same profession, with
the same class of license, as the defendant. For affidavits filed as
to all other defendants, the written report must be from a
physician licensed to practice medicine in all its branches." 735
ILCS 5/2-622(a)(1) (West 2000).
Plaintiff asserts that section 2-622 evinces a legislative intent that
physicians are competent to testify about the standard of care for the
nursing profession.
	We cannot accept this contention. The written health professional
report required by section 2-622(a)(1) is a pleading requirement designed
to reduce the number of frivolous medical malpractice lawsuits at an early
stage before litigation expenses mount. DeLuna v. St. Elizabeth's
Hospital, 147 Ill. 2d 57, 65 (1992). The health professional's report
establishes only that the plaintiff has a meritorious claim and, therefore,
reasonable grounds for pursuing the action. The requirements of section
2-622 do not rise to the level of substantive elements of a claim for
medical malpractice. Gulley v. Noy, 316 Ill. App. 3d 861, 864 (2000);
Mueller v. North Suburban Clinic, Ltd., 299 Ill. App. 3d 568, 573
(1998). The report constitutes only a threshold opinion, based on a health
professional's overview of the case. The health professional's report
constitutes only "an advisory opinion." McAlister v. Schick, 147 Ill. 2d 84, 93 (1992). Because the purpose of section 2-622 is to eliminate
frivolous lawsuits at the pleading stage, the statute has no bearing on the
type of evidence relied upon at trial. Lyons v. Hasbro Industries, Inc.,
156 Ill. App. 3d 649, 655 (1987). Further, the fact that Jones and Gill,
which clearly uphold Dolan's license requirement, were decided
subsequent to the enactment of section 2-622 belies any tension between
the statute and this court's precedent.
	Plaintiff next cites Wingo v. Rockford Memorial Hospital, 292 Ill.
App. 3d 896 (1997), in support of her argument against the requirement
that a health-care expert witness must be licensed in the school of
medicine of which the expert proposes to testify. Plaintiff contends that if
Wingo is applied to this case, Dr. Barnhart should be allowed to testify to
the standard of care applicable to nurse Lewis.
	In Wingo, three physician expert witnesses testified that a nurse
deviated from the applicable nursing standard of care by failing to properly
communicate the condition of a patient to the treating physician. The
physicians opined that the nurse's deviation from the standard of care
resulted in a baby being born with brain damage. Wingo, 292 Ill. App. 3d
at 903-04.
	The court in Wingo distinguished that case from this court's
precedent and held that the license requirement of Dolan did not apply:
			"We find that the facts of the instant case do not fit within the
license requirement of Dolan or Jones. Those cases indicate that
the reason for the rule is to prevent a higher standard of care
being imposed upon the defendant and to ensure that the
testifying expert has expertise in dealing with the patient's
medical problem and treatment and that the allegations of
negligence are within the expert's knowledge and observation.
Those concerns have not been sacrificed here. In the instant
case, the allegations of negligence against nurse Welden did not
concern a nursing procedure but, rather, related to what a nurse
is required to communicate to a physician about what transpired
since the physician last saw the patient. As such the allegations
of negligence do not concern an area of medicine about which
there would be a different standard between physician and
another school of medicine. Furthermore, it was established that
the allegations of negligence were well within the testifying
doctors' knowledge and experience. We believe that a physician
should be entitled to testify about what he or she is entitled to
rely upon in the area of communication from a nurse in the
context of an obstetrical team rendering care to a patient in a
hospital." Wingo, 292 Ill. App. 3d at 906.
Accordingly, the court held that no error occurred in allowing the
physicians to testify as to the applicable nursing standard of care in that
case. Wingo, 292 Ill. App. 3d at 906.
	The appellate court in this case correctly reasoned that Wingo does
not apply. In this case, the trial court struck Dr. Barnhart's testimony
regarding nurse Lewis' communication with Dr. Conte-Russian as a
sanction for violating Rule 213(g). Thus, the precise factual scenario of
Wingo is not present. Dr. Barnhart's remaining opinion testimony related
to nursing procedures. 335 Ill. App. 3d at 271. In distinguishing Wingo
from this case, the appellate court did not discuss the merits of Wingo,
and neither do we. The present case falls squarely within the license
requirement of Dolan and its progeny.
	Accordingly, what remains for us is to apply Dolan's license
requirement for health-care expert witnesses to the remainder of Dr.
Barnhart's testimony. As noted, Dr. Barnhart testified that nurse Lewis
failed to adhere to proper nursing procedures. He opined that nurse Lewis
should have pursued her concerns that Burns was a fall risk by going up
the nursing chain of command; that she should have provided for an
alternative to the posey vest; and that she should have provided for
constant supervision.
	We agree with the trial and appellate courts that, based on Dolan,
Dr. Barnhart was not competent to testify regarding the standard of care
for the nursing profession and nurse Lewis' deviations therefrom. Dolan
specifically included the nursing profession in discussing its rationale for the
license requirement. This court acknowledged that the legislature
established nursing as a unique school of medicine. Dolan, 77 Ill. 2d  at
284. Further, the dissent in Dolan lends support to the conclusion that
Dolan's licensing requirement includes the nursing profession. The dissent
stated: "Under [this] holding a physician would be unable to testify to
nursing standards of care even though nurses operated under [the
physician's] supervision or to testify to standards for midwives, and this
because the physician was not licensed as a nurse or a midwife." Dolan,
77 Ill. 2d  at 286 (Ward, J., dissenting, joined by Goldenhersh, C.J.).
Clearly, this exact issue was contemplated by this court in Dolan, which
unequivocally required that a health-care expert witness must be a
licensed member of the school of medicine about which the expert
testifies.
	We note that amicus Illinois Trial Lawyers Association expressly
agrees with the Dolan dissent and contends that the license requirement
should not be a threshold test. The Trial Lawyers Association posits:
"There is nothing which a nurse can do which a doctor cannot do." To be
sure, this supposition is generally accepted. Amicus American Association
of Nurse Attorneys (AANA) concedes that in many jurisdictions
physicians have been allowed to testify as to the nursing standard of care.
See, e.g., Paris v. Kreitz, 75 N.C. App. 365, 380, 331 S.E.2d 234, 245
(1985) (noting that "physicians are clearly acceptable experts with regard
to *** nurses"); Goff v. Doctors General Hospital, 166 Cal. App. 2d 314, 319-20, 333 P.2d 29, 33 (1958) (reasoning that "surely, a qualified
doctor would know what was standard procedure for nurses to follow").
	However, the proposition that "[t]here is nothing which a nurse can
do which a doctor cannot do" presumes a universal standard of treatment
among physicians and nurses. Dolan expressly rejected this assumption.
Dolan, 77 Ill. 2d  at 284 (rejecting the assumption "that science and
medicine have achieved a universal standard of treatment of disease or
injury"). AANA persuasively reasons:
			"A physician, who is not a nurse, is no more qualified to offer
expert, opinion testimony as to the standard of care for nurses
than a nurse would be to offer an opinion as to the physician
standard of care. *** Certainly, nurses are not permitted to offer
expert testimony against a physician based on their observances
of physicians or their familiarity with the procedures involved. An
operating room nurse, who stands shoulder to shoulder with
surgeons every day, would not be permitted to testify as to the
standard of care of a surgeon. An endoscopy nurse would not be
permitted to testify as to the standard of care of a
gastroenterologist performing a Colonoscopy. A labor and
delivery nurse would not be permitted to offer expert, opinion
testimony as to the standard of care for an obstetrician or even
a midwife. Nor would a nurse be permitted to testify that, in her
experience, when she calls a physician, he/she usually responds
in a certain manner. Such testimony would be, essentially, expert
testimony as to the standard of medical care."
Scholars share this reasoning:
		"Physicians often have no first-hand knowledge of nursing
practice except for observations made in patient care settings.
The physician rarely, if ever, teaches in a nursing program nor is
a physician responsible for content in nursing texts. In many
situations, a physician would not be familiar with the standard of
care or with nursing policies and procedures which govern the
standard of care. Therefore, a physician's opinions would not be
admissible in jurisdictions which hold the expert must be familiar
with the standard of care in order to testify as an expert. An
example of a common situation which gives rise to allegations of
nursing negligence occurs when a nurse fails to follow the
institutional 'chain of command' in reporting a patient condition
to a physician who subsequently refuses to attend to the patient
condition. It is unlikely that a physician would be familiar with the
policy and procedure involved in handling such a situation. It is
as illogical for physicians to testify on nursing standard of care as
it would be for nurses to testify about medical malpractice." E.
Beyer & P. Popp, Nursing Standard of Care in Medical
Malpractice Litigation: The Role of the Nurse Expert
Witness, 23 J. Health & Hosp. L. 363, 365 (1990).
This scholarly insight has spread to litigators:
			"Testimony from a physician about the standard of care may
be subject to objection because the physician is not a nurse and
does not have direct knowledge of nursing standards of care. A
physician's statement that he or she often observes nurses and
therefore knows what they do may be inadequate." P. Sweeney,
Proving Nursing Negligence, 27 Trial 34, 36 (May 1991).
Beyond scholars and litigators, courts have begun to accept this reasoning.
	In some jurisdictions, "the physician is no longer permitted to testify
about the nursing standard of care since the physician is not a nurse and
does not possess direct knowledge of nursing standards." F. Cavico & N.
Cavico, The Nursing Profession in the 1990's: Negligence and
Malpractice Liability, 43 Clev. St. L. Rev. 557, 578 (1995); see Dolan
v. Jaeger, 285 A.D.2d 844, 846, 727 N.Y.S.2d 784, 786-87 (2001)
(upholding trial court's dismissal of nursing malpractice action where
physician anesthesiologist was only expert to testify as to nurse's standard
of care); Vassey v. Burch, 45 N.C. App. 222, 226, 262 S.E.2d 865, 867 ("Although the affidavit of [the physician] may be sufficient to
establish the accepted standard of medical care for a doctor in his office,
it does not establish the standard of care for a nurse in a hospital"), rev'd
on other grounds, 301 N.C. 68, 269 S.E.2d 137 (1980). According to
one scholar:
			"These cases represent a growing recognition on the part of
courts that nursing, as a profession, has moved beyond its former
dependence on the physician, and into a realm where it must and
can legally account for its own professional practices. In doing
so, the experts who provide the testimony, and the literature from
which their opinions are derived, come from the nursing
profession." C. Kehoe, Contemporary Nursing Roles and
Legal Accountability: The Challenge of Nursing Malpractice
for the Law Librarian, 79 Law Libr. J. 419, 428-29 (1987).
Based on this reasoning, AANA argues that Dr. Barnhart should not be
permitted to offer expert testimony against nurse Lewis based on his
observation of nurses.
	We agree. By enacting the Nursing and Advanced Practice Nursing
Act (225 ILCS 65/5-1 et seq. (West 2000)), the legislature has set forth
a unique licensing and regulatory scheme for the nursing profession. As
AANA observes, under the nursing act, a person with a medical degree,
who is licensed to practice medicine, would not meet the qualification for
licensure as a registered nurse, nor would that person be competent to sit
for the nursing license examination, unless that person completed an
accredited program in nursing. See 225 ILCS 65/5-1 et seq. (West
2000). The appellate court in this case correctly reasoned:
		"Dr. Barnhart is not a licensed member of the nursing profession.
To allow the doctor to testify as to the standard of care
applicable to the nursing profession implicates the risks raised by
Dolan, namely, the imposition of a higher standard of care and
the muddling and mixing of various tenets and practices unique
to each profession." 335 Ill. App. 3d at 272.
We uphold the trial court's ruling on the competency of Dr. Barnhart to
testify as to the standard of care for the nursing profession. We expressly
reaffirm the license requirement of Dolan and its progeny and decline
plaintiff's invitation to deviate therefrom.
	As a consequence of ruling that Dr. Barnhart was not competent to
testify as to the standard of care for the nursing profession, the trial court
entered a directed verdict in favor of the hospital. A directed verdict will
be upheld where "all of the evidence, when viewed in its aspect most
favorable to the opponent, so overwhelmingly favors movant that no
contrary verdict based on that evidence could ever stand." Pedrick v.
Peoria & Eastern R.R. Co., 37 Ill. 2d 494, 510 (1967). A directed
verdict in favor of a defendant is appropriate when the plaintiff has not
established a prima facie case. A plaintiff must present at least some
evidence on every essential element of the cause of action or the defendant
is entitled to judgment in his or her favor as a matter of law. Nastasi v.
United Mine Workers of American Union Hospital, 209 Ill. App. 3d
830, 837 (1991). If the plaintiff fails to produce a required element of
proof in support of her cause of action, then no cause is presented for the
jury's consideration and the entry of a directed verdict for the defendant
is proper. Mayer v. Baisier, 147 Ill. App. 3d 150, 155 (1986); see 3A
Nichols Illinois Civil Practice §62:9 (rev. 2003).
	In this case, plaintiff was required, and failed, to establish the
applicable standard of care through the testimony of a medical expert. The
only evidence plaintiff offered on this issue was the testimony of Dr.
Barnhart, which the trial court properly struck. Therefore, plaintiff failed
to establish a prima facie case of medical malpractice against the hospital
through the acts of nurse Lewis. The trial court correctly determined as a
matter of law that there was no evidentiary basis out of which the jury
could have construed the necessary facts essential to recovery. See Jones,
154 Ill. 2d  at 47. We uphold the trial court's directed verdict in favor of
the hospital.

II. Jury Instruction on Proximate Cause
	Plaintiff next contends that the trial court committed reversible error
by giving the jury the long-form proximate cause instruction from Illinois
Pattern Jury Instructions, Civil, No. 12.05 (2000). According to plaintiff,
the evidence did not show another party to be the sole proximate cause
of Burns' injuries.
	We need not address this contention, as it is waived. Supreme Court
Rule 315(b)(3) requires a petition for leave to appeal to contain "a
statement of the points relied upon for reversal of the judgment of the
Appellate Court." 177 Ill. 2d R. 315(b)(3). Rule 315(b)(5) requires the
petition to contain "a short argument *** stating *** why the decision of
the Appellate Court should be reversed or modified." 177 Ill. 2d R.
315(b)(5). In this case, the "points relied upon for reversal" and
"argument" sections of plaintiff's petition for leave to appeal focused
exclusively on the issue of the competency of Dr. Barnhart to testify as to
the standard of care for the nursing profession.
	Plaintiff concedes that she did not raise this issue in the petition for
leave to appeal. However, in a footnote in her brief, plaintiff claims that
Caveney v. Bower, 207 Ill. 2d 82 (2003), allows her to assert this issue.
We disagree. In Caveney, the appellant did raise the contested issue in
the petition for leave to appeal (Caveney, 207 Ill. 2d at 86-87), but here,
plaintiff did not. It is quite established that issues not presented in the
petition for leave to appeal are not properly before this court and are
deemed waived. In re A.W.J., 197 Ill. 2d 492, 499 (2001) (and cases
cited therein); Rodgers v. St. Mary's Hospital, 149 Ill. 2d 302, 313
(1992).
	However, plaintiff invokes an exception to the waiver rule. Certainly,
it is within our discretion to address the merits of an issue not properly
raised in an appellant's petition for leave to appeal. Deal v. Byford, 127 Ill. 2d 192, 200-01 (1989). This court has explained that:
			"the waiver rule is a principle of administrative convenience,
an admonition to the parties; it is not a jurisdictional requirement
or any limitation upon the jurisdiction of a reviewing court. In this
regard, this court has recognized that a reviewing court may, in
furtherance of its responsibility to provide a just result and to
maintain a sound and uniform body of precedent, override
considerations of waiver that stem from the adversarial nature of
our system." Dillon v. Evanston Hospital, 199 Ill. 2d 483,
504-05 (2002).
Accord People v. Ward, 113 Ill. 2d 516, 523 (1986), citing 87 Ill. 2d R.
366(a)(5).
	In this case, we see no reason to override plaintiff's waiver of this
issue. The appellate court fully considered the question of whether the
long-form proximate cause instruction was properly given to the jury. 335
Ill. App. 3d at 273-74. We therefore conclude that further review of this
issue is unnecessary. See A.W.J., 197 Ill. 2d  at 500; Ward, 113 Ill. 2d  at
523.

CONCLUSION
	For the foregoing reasons, the judgment of the appellate court is
affirmed.
Affirmed.
	JUSTICE RARICK, concurring in part and dissenting in part:
	I concur with the majority's holding that the trial court did not abuse
its discretion in finding that plaintiff violated Supreme Court Rule 213(g)
(177 Ill. 2d R. 213(g)), and in striking this portion of Dr. Barnhart's
testimony. However, I cannot agree with the majority's conclusion that Dr.
Barnhart was not competent to testify to the standard of care applicable
to the nursing profession in this case.
	The majority holds that this case "falls squarely within the license
requirement of Dolan [v. Galluzzo, 77 Ill. 2d 279 (1979)]" (slip op. at
14), and rejects plaintiff's reliance on Wingo v. Rockford Memorial
Hospital, 292 Ill. App. 3d 896 (1997), which set forth an exception
whereby physicians may testify regarding "what a nurse is required to
communicate to a physician." Wingo, 292 Ill. App. 3d at 906. While the
majority finds that "the precise factual scenario of Wingo" (slip op. at 14)
is not present in the instant case, I believe that any factual distinctions are
insignificant where the rationale behind the Wingo decision fully applies.
	 While declining to address the merits of Wingo, the majority notes
Wingo's holding that the reason for the license requirement of Dolan is to
" 'prevent a higher standard of care being imposed upon the defendant
and to ensure the testifying expert has expertise in dealing with the
patient's medical problem and treatment and that the allegations of
negligence are within the expert's knowledge and observation.' " Slip op.
at 14, quoting Wingo, 292 Ill. App. 3d at 906. The majority also
acknowledges that Dr. Barnhart has "substantial experience in observing
and working with physicians and nurses in the area of patient fall
protection." (Emphasis added.) Slip op. at 3. Therefore here, as in Wingo,
the concerns expressed in Dolan are not at issue because the record
establishes that Dr. Barnhart's particular expertise encompasses the
proper standard of care for both physicians and nurses pertaining to
patient fall protection. Thus, I would adopt the reasoning of Wingo which
holds that the license requirements of Dolan do not apply where the
allegations of negligence "do not concern an area of medicine about which
there would be a different standard between physician and another school
of medicine." Wingo, 292 Ill. App. 3d at 906.
	For the foregoing reasons, I would hold that the circuit court erred
in granting a directed verdict for the hospital because Dr. Barnhart was
competent to testify as to nurse Lewis' deviations from the proper
procedures in the area of patient fall protection. The judgments of the
appellate and circuit courts should be reversed in part. Accordingly, I
respectfully dissent.