Case Title: Neade v. Portes

Citation: 

Docket Number: 87445

State: illinois

Court: Illinois Supreme Court

Date: 2000-10-26T00:00:00Z

Document:
Docket No. 87445-Agenda 30-May 2000.
THERESE NEADE, as Independent Adm'r of the Estate of 
Anthony Robert Neade, Deceased, Appellee, v. STEVEN PORTES et al., Appellants.
Opinion filed October 26, 2000.
	JUSTICE McMORROW delivered the opinion of the court:
	Plaintiff filed a three-count complaint in the circuit court of
Lake County, two counts of which were directed against
defendants Steven Portes and Primary Care Family Center. In
count I, plaintiff alleged that defendants were liable for medical
negligence, and in count II, plaintiff charged defendants with a
breach of fiduciary duty. The principle issue in this appeal is
whether, in a complaint alleging medical negligence, a patient has
a cause of action for breach of fiduciary duty against a physician
for that physician's failure to disclose incentives that exist under
the physician's arrangement with the patient's health maintenance
organization (HMO). We hold that a patient may not bring a
breach of fiduciary duty claim against a physician under these
circumstances.
BACKGROUND 
	According to the allegations in plaintiff Therese Neade's
complaint, plaintiff's husband, Anthony Neade, had a family
history of heart disease, suffered from hypertension and a high
cholesterol count, smoked heavily and was overweight. In 1990,
at age 37, Mr. Neade began to exhibit symptoms of coronary artery
blockage. Specifically, Mr. Neade experienced chest pain
extending into his arm and shortness of breath. Mr. Neade's
primary care physician, Steven Portes, M.D., hospitalized Mr.
Neade from August 10 through August 13, 1990. During this
hospitalization, Mr. Neade received several tests, including a
thallium stress test and an electrocardiogram (EKG). Dr. Thomas
Engel (not a party to this appeal) found the results of the tests to
be normal and diagnosed Mr. Neade with hiatal hernia and/or
esophagitis. Mr. Neade was thereafter discharged.
	After his hospitalization, Mr. Neade visited Dr. Portes on
August 17, August 28 and September 24, 1990, at the Primary
Care Family Center (Primary Care), complaining of continued
chest pain radiating to his neck and arm. Relying on the results of
the thallium stress test and EKG taken during Mr. Neade's
hospitalization, Dr. Portes informed Mr. Neade that his chest pain
was not cardiac related. In October 1990, Mr. Neade returned to
Dr. Portes, this time complaining of stabbing chest pain. At the
request of Dr. Portes, his associate, Dr. Huang, examined Mr.
Neade. Dr. Huang recommended that Mr. Neade undergo an
angiogram-a test that is more specific for diagnosing coronary
artery disease than a thallium stress test. Dr. Huang was employed
on a part-time basis at Primary Care and had no hospital
privileges. Dr. Portes, as Mr. Neade's primary care physician, was
responsible for ordering any necessary hospitalization or
additional tests. Despite Dr. Huang's recommendation, Dr. Portes
did not authorize an angiogram for Mr. Neade.
	Mr. Neade again returned to Primary Care in June 1991,
complaining of chest pain. Dr. Portes asked Dr. Schlager, another
part-time physician at Primary Care, to examine Mr. Neade. After
this examination, Dr. Schlager also recommended that Mr. Neade
undergo an angiogram, but Dr. Portes, relying on the thallium
stress test, did not authorize the angiogram and advised Dr.
Schlager that Mr. Neade's chest pain was not cardiac related.
Subsequently, on September 16, 1991, Mr. Neade suffered a
massive myocardial infarction caused by coronary artery blockage.
Nine days later, Mr. Neade died.
	Plaintiff's complaint alleges that Dr. Portes was the president
of Primary Care and, as such, negotiated contracts with various
organizations on behalf of himself and the clinic. Chicago HMO,
of which Mr. Neade was a member, was one of the organizations
with which Dr. Portes had contracted for the provision of services.
According to plaintiff's complaint, Dr. Portes personally
negotiated with Chicago HMO in 1990 and 1991 and agreed that
Dr. Portes and his group would receive from Chicago HMO, inter
alia, $75,000 annually. The $75,000 was to be used by Dr. Portes
and his group to cover costs for patient referrals and outside
medical tests prescribed for Chicago HMO members. This fund
was termed the "Medical Incentive Fund."
	Pursuant to the contract between Dr. Portes, Primary Care and
Chicago HMO, any portion of the Medical Incentive Fund that
was not used for referrals or outside tests would be divided at the
end of each year between Primary Care's full time physicians and
Chicago HMO, with the physicians receiving 60% of the
remaining money and Chicago HMO receiving 40%. If the
Medical Incentive Fund was exhausted prior to the end of the year,
Dr. Portes and his group would be required to fund any additional
consultant fees and outside tests. Plaintiff and Mr. Neade were not
informed of this arrangement between Dr. Portes, Primary Care
and Chicago HMO.
	Count I of plaintiff's amended complaint alleges that Dr.
Portes' reliance on the thallium stress test and EKG and his failure
to authorize an angiogram constituted medical negligence which
proximately resulted in Mr. Neade's death. In count I, plaintiff
alleged facts regarding the Medical Incentive Fund. Count II of
plaintiff's amended complaint alleges that Dr. Portes had a
fiduciary duty to act in good faith and in the best interest of Mr.
Neade, and that he breached that duty by refusing to authorize
further testing, by refusing to refer Mr. Neade to a specialist and
by refusing to disclose to the Neades Dr. Portes' financial
relationship (including the Medical Incentive Fund) with Chicago
HMO. Count II further alleges that Dr. Portes breached his
fiduciary duty by entering into a contract with Chicago HMO that
put his financial well-being in direct conflict with Mr. Neade's
physical well-being.
	The trial court agreed with defendants' argument that
financial motive was not relevant to whether Dr. Portes violated
the applicable standard of care in treating Mr. Neade. The trial
court therefore struck the allegations relating to the Medical
Incentive Fund from count I. With respect to count II, the trial
court found that there existed no cause of action against a
physician for breach of fiduciary duty and granted defendants'
motion to dismiss. Plaintiff thereafter filed a motion to reconsider,
to which she attached her own affidavit and portions of the
deposition of plaintiff's expert, Dr. Jay Schapira. Plaintiff's
affidavit stated that, if she had known of the Medical Incentive
Fund, she would have sought a second opinion from a physician
outside of Dr. Portes' group concerning the necessity of an
angiogram. In his deposition, Dr. Schapira stated that both the
applicable standard of care and ethical considerations obligate a
doctor to disclose his financial interest in withholding care.
According to Dr. Schapira, a patient can then make an informed
decision concerning the quality of care he is receiving and his
doctor's motivations in treating him. Defendants filed a motion to
strike the affidavit and deposition excerpts from plaintiff's motion
to reconsider. The trial court denied defendants' motion to strike
and also denied plaintiff's motion to reconsider.
	On appeal, plaintiff argued that allegations concerning the
Medical Incentive Fund are relevant to count I of plaintiff's
complaint, in which plaintiff alleged medical negligence, to show
that Dr. Portes deviated from the standard of care. The appellate
court determined that allegations relating to financial motive are
not appropriate in a medical negligence claim, and affirmed the
trial court's holding on this issue. However, the appellate court
held that evidence relating to the Medical Incentive Fund may be
relevant at trial to attack Dr. Portes' credibility if he testifies. The
appellate court reversed the trial court's dismissal of count II and
held that plaintiff stated a cause of action for breach of fiduciary
duty against Dr. Portes for Dr. Portes' failure to disclose the
Medical Incentive Fund. 303 Ill. App. 3d 799.
	On appeal to this court, defendants argue for reversal of the
appellate court's finding that: (1) a cause of action for breach of
fiduciary duty exists for Dr. Portes' failure to disclose the Medical
Incentive Fund; and (2) evidence of the Medical Incentive Fund is
relevant in plaintiff's medical negligence action if Dr. Portes
testifies at trial. We allowed the Illinois Trial Lawyers Association
to file an amicus curiae brief in support of plaintiff and the Illinois
State Medical Society and American Medical Association to file
an amicus curiae brief in support of defendant.
ANALYSIS
	 A motion to dismiss under section 2-615 of the Code of Civil
Procedure (735 ILCS 5/2-615 (West 1998)) is properly granted
where the plaintiff fails to state a cause of action upon which relief
can be granted. Abbasi v. Paraskevoulakos, 187 Ill. 2d 386, 391
(1999). We review a section 2-615 motion to dismiss de novo.
Abbasi, 187 Ill. 2d  at 391, citing Vernon v. Schuster, 179 Ill. 2d 338, 344 (1997).
I. Breach of Fiduciary Duty
	The primary issue in this appeal is whether plaintiff can state
a cause of action for breach of fiduciary duty against Dr. Portes for
Dr. Portes' failure to disclose his interest in the Medical Incentive
Fund. A fiduciary relationship imposes a general duty on the
fiduciary to refrain from "seeking a selfish benefit during the
relationship." Kurtz v. Solomon, 275 Ill. App. 3d 643, 651 (1995),
citing Collins v. Nugent, 110 Ill. App. 3d 1026, 1036 (1982).
Illinois courts have recognized a fiduciary relationship between a
physician and his patient (Witherell v. Weimer, 118 Ill. 2d 321, 331
(1987); Petrillo v. Syntex Laboratories, Inc., 148 Ill. App. 3d 581,
587 (1986)), but Illinois courts have never recognized a cause of
action for breach of fiduciary duty against a physician.
	Though Illinois courts have never addressed the issue of
whether a plaintiff can state a cause of action for breach of
fiduciary duty against a physician, courts have rejected breach of
fiduciary duty claims brought against attorneys on the basis that
they are duplicative of negligence or malpractice claims. For
example, our appellate court has held that where a claim for legal
malpractice and a claim for breach of fiduciary duty are based on
the same operative facts and result in the same injury to the
plaintiff, the breach of fiduciary duty claim should be dismissed as
duplicative. Majumdar v. Lurie, 274 Ill. App. 3d 267, 273-74
(1995); Calhoun v. Rane, 234 Ill. App. 3d 90, 95 (1992).
	Courts in other jurisdictions have dismissed claims for breach
of fiduciary duty when those claims are duplicative of medical
negligence claims. Such claims for breach of fiduciary duty have
also been dismissed where they constitute an impermissible
recasting of a medical negligence claim, even though plaintiff's
complaint did not include a medical negligence claim. The
appellate court in the case at bar discussed decisions from
Minnesota, Colorado, Arizona and New Mexico. Each of these
jurisdictions held that a breach of fiduciary duty claim is
duplicative of a negligence claim. 303 Ill. App. 3d at 809-10,
citing Hales v. Pittman, 118 Ariz. 305, 309, 576 P.2d 493, 497
(1978)); D.A.B. v. Brown, 570 N.W.2d 168 (Minn. App. 1997);
Garcia v. Coffman, 124 N.M. 12, 19, 946 P.2d 216, 223 (App.
1997); Awai v. Kotin, 872 P.2d 1332, 1337 (Colo. App. 1993);
Spoor v. Serota, 852 P.2d 1292, 1294-95 (Colo. App. 1992). For
example, in Brown, the defendant physician prescribed the drug
Protopin to a group of patients. Subsequently, the defendant and
the distributor of Protopin were indicted for violating the
Medicaid/Medicare Anti Kickback statute (42 U.S.C. §§1320(a)
through 7b(b) (1994)). The distributer admitted that it made
payments to the defendant in exchange for prescribing Protopin-related treatment. The plaintiff class, which consisted of the
defendant's patients, filed suit against the defendant for breach of
fiduciary duty for the defendant's failure to disclose the
"kickback" scheme. The Minnesota appellate court upheld the trial
court's dismissal of the plaintiffs' claim because it found that the
"gravamen of the complaint sound[ed] in medical malpractice."
Brown, 570 N.W.2d  at 171. Specifically, the Brown court was
concerned that plaintiffs would plead claims for breach of
fiduciary duty, rather than medical malpractice, in order to avoid
statutes of limitations and the requirement of proving actual injury.
The Brown court found that creation of a new cause of action for
breach of fiduciary duty was unnecessary, stating that "[a]ny
breach of fiduciary duty that may have occurred during the
doctor's prescription of medication to his patients arose while the
doctor was examining, diagnosing, treating, or caring for his
patients" and thus constituted a claim for medical negligence.
Brown, 570 N.W.2d  at 172.
	In a case involving facts similar to the case at bar, the United
States Supreme Court recently refused to recognize a breach of
fiduciary duty under ERISA. Pegram v. Herdrich, 530 U.S. ___,
147 L. Ed. 2d 164, 120 S. Ct. 2143 (2000). In Herdrich, the
plaintiff, a member of the Carle Clinic Association, P.C., Health
Alliance Medical Plans, Inc., and Carle Health Insurance
Management Co., Inc. (collectively Carle), an HMO, visited her
primary care physician complaining of groin pain. The following
week, the physician found an inflamed mass in the plaintiff's
abdomen. The physician required the plaintiff to wait eight days
to receive an ultrasound at a Carle facility over 50 miles away. In
the interim, the plaintiff's appendix ruptured, causing peritonitis.
The plaintiff filed a suit for both medical malpractice against her
physician and breach of fiduciary duty against Carle. The breach
of fiduciary duty claim alleged that Carle's act of providing
incentives for its physicians to limit medical care and procedures
constituted a breach of fiduciary duty under ERISA. Herdrich, 530
U.S. at ___, 147 L. Ed. 2d  at 173, 120 S. Ct.  at 2147. The Supreme
Court reversed the Seventh Circuit's determination that the
plaintiff stated a cause of action for breach of fiduciary duty under
ERISA. Herdrich, 530 U.S. at ___, 147 L. Ed. 2d  at 186, 120 S. Ct.  at 2158-59. The Supreme Court noted the nature of a breach of
fiduciary claim against an HMO physician. The Court stated:
		"[T]he defense of any HMO would be that its physician
did not act out of financial interest but for good medical
reasons, the plausibility of which would require reference
to standards of reasonable and customary medical practice
in like circumstances. That, of course, is the traditional
standard of the common law. [Citation.] Thus, for all
practical purposes, every claim of fiduciary breach by an
HMO physician making a mixed decision [about a
patient's eligibility for treatment under an HMO and the
appropriate treatment for the patient] would boil down to
a malpractice claim, and the fiduciary standard would be
nothing but the malpractice standard traditionally applied
in actions against physicians." Herdrich, 530 U.S. at ___,
147 L. Ed. 2d  at 185, 120 S. Ct.  at 2157.
See also B. Furrow, Managed Care Organizations and Patient
Injury: Rethinking Liability, 31 Ga. L. Rev. 419, 484 (1997).
	We find the reasoning in the foregoing cases persuasive in
analysis of the case at bar and decline to uphold plaintiff's breach
of fiduciary duty claim. The appellate court held that because
plaintiff pled different facts in support of her breach of fiduciary
duty claim from those facts pled in her medical negligence claim,
she stated two separate causes of action. Though many of the facts
pled in counts I and II are identical, in her breach of fiduciary duty
claim, plaintiff did plead the additional fact that Dr. Portes failed
to disclose the Medical Incentive Fund. However, as our appellate
court in Majumdar stated, it is operative facts together with the
injury that we look to in order to determine whether a cause of
action is duplicative. In the case at bar, the operative fact in both
counts is Dr. Portes' failure to order an angiogram for Mr. Neade.
Plaintiff alleges in both counts that Mr. Neade's failure to receive
an angiogram is the ultimate reason for his subsequent death.
Plaintiff also alleges the same injury in both her medical
negligence claim and her breach of fiduciary duty claim, namely,
Mr. Neade's death and its effect on plaintiff and her family. We
determine that plaintiff's breach of fiduciary duty claim is a re-presentment of her medical negligence claim.
	An examination of the elements of a medical negligence claim
and breach of fiduciary duty claim illustrates the way in which a
breach of fiduciary duty claim would "boil down to a malpractice
claim." Herdrich, 530 U.S. at ___, 147 L. Ed. 2d  at 185, 120 S. Ct. 
at 2157. To sustain an action for medical negligence, plaintiff must
show: (1) the standard of care in the medical community by which
the physician's treatment was measured; (2) that the physician
deviated from the standard of care; and (3) that a resulting injury
was proximately caused by the deviation from the standard of care.
Purtill v. Hess, 111 Ill. 2d 229, 241-42 (1986). Thus, the standard
of care is the relevant inquiry by which we judge a physician's
actions in a medical negligence case. Under a standard of care
analysis, a defendant will be held to "the reasonable skill which a
physician in good standing in the community would use in a
similar case." Newell v. Corres, 125 Ill. App. 3d 1087, 1094
(1984). If a physician deviates from the standard of care and that
deviation proximately causes injury to a patient, the physician is
liable for damages caused by his medical negligence.
	In contrast to an action for medical negligence, in order to
state a claim for breach of fiduciary duty, it must be alleged that a
fiduciary duty exists, that the fiduciary duty was breached, and 
that such breach proximately caused the injury of which the
plaintiff complains. Martin v. Heinold Commodities, Inc., 163 Ill. 2d 33, 53 (1994); see also Chicago City Bank & Trust Co. v.
Lesman, 186 Ill. App. 3d 697, 701 (1989) ("[a] cause of action for
breach of fiduciary duty must set forth *** that a fiduciary
relationship existed between the parties, that the trustee owed
certain, specific duties to the plaintiff, that the trustee breached
those duties, and that there were resulting damages"). In the case
at bar, plaintiff alleged in her complaint that "as a direct and
proximate result of Defendant's breach of fiduciary duty ***,
Anthony Neade suffered a massive myocardial infarction." The
appellate court agreed, holding that "[i]t is conceivable that a trier
of fact could find *** that Dr. Portes did breach his fiduciary duty
in not disclosing his financial incentive arrangement and, as a
proximate result thereof, Neade did not obtain a second opinion,
suffered a massive coronary infarction, and died." 303 Ill. App. 3d
at 814.
	In order to sustain a breach of fiduciary duty claim against Dr.
Portes, plaintiff would have to allege, inter alia, that: (1) had she
known of the Medical Incentive Fund she would have sought an
opinion from another physician; (2) that the other physician would
have ordered an angiogram for Mr. Neade; (3) that the angiogram
would have detected Mr. Neade's heart condition; and (4) that
treatment could have prevented his eventual myocardial infarction
and subsequent death. See, e.g., Newell, 125 Ill. App. 3d at 1094.
In order to prove the second element, plaintiff would have been
required to present expert testimony that the expert, after
examining Mr. Neade and considering his history, would have
ordered an angiogram. This requirement relates to the standard of
care consideration-the first prong in a traditional medical
negligence claim-under which a physician is held to "the
reasonable skill which a physician in good standing in the
community would use." Newell, 125 Ill. App. 3d at 1094. That is
precisely what plaintiff must prove to support her breach of
fiduciary duty claim. As the Supreme Court stated in Herdrich, the
breach of fiduciary duty claim "would boil down to a malpractice
claim, and the fiduciary standard would be nothing but the
malpractice standard traditionally applied in actions against
physicians." Herdrich, 530 U.S. at ___, 147 L. Ed. 2d  at 185, 120 S. Ct.  at 2157. Thus, we need not recognize a new cause of action
for breach of fiduciary duty when a traditional medical negligence
claim sufficiently addresses the same alleged misconduct. The
breach of fiduciary duty claim in the case at bar would be
duplicative of the medical negligence claim.
	An examination of the damages pled in plaintiff's complaint
further supports our conclusion that a medical negligence claim
sufficiently addresses plaintiff's injuries. While pleading in the
alternative is generally permitted (see, e.g., Collins v. Reynard,
154 Ill. 2d 48, 50 (1992)), duplicate claims are not permitted in the
same complaint. Count I of plaintiff's amended complaint sounds
in medical negligence committed by Dr. Portes. In count I,
plaintiff alleges that Mr. Neade's death deprived plaintiff and her
children of Mr. Neade's "companionship as well as other attributes
that they would normally receive as wife and children respectively,
now and in the future, as well as the support of money and
valuable services which he had provided." Plaintiff requests
$50,000 in addition to costs of the law suit in damages under count
I. Count II of plaintiff's amended complaint attempts to state a
cause of action for Dr. Portes' breach of fiduciary duty. The
damages alleged in count II are identical to those alleged in count
I. Here, though attempting to couch the claim in different terms,
plaintiff is essentially pleading the same cause of action which
caused the same damages.
	Our decision to refrain from permitting the creation of this
new cause of action finds additional support in statutory law. The
Illinois legislature has placed the burden of disclosing HMO
incentive schemes on HMOs themselves. The Illinois General
Assembly recently enacted the Managed Care Reform and Patient
Rights Act (hereinafter, the Managed Care Act), which states:
"Upon written request, a health care plan shall provide to enrollees
a description of the financial relationships between the health care
plan and any health care provider ***." 215 ILCS 134/15(b) (West
Supp. 1999). The Managed Care Act, effective on January 1, 2000,
requires that managed care organizations disclose physician
incentive plans to patients. Thus, the legislature has chosen to put
the burden of disclosing any financial incentive plans on the
HMO, rather than on the physician. The legislature has put the
burden of disclosure on the entities that create financial incentive
plans and require physicians to adhere to them. If the legislature
had wished to place the burden of disclosing financial incentives
on physicians, it could have done so.
	Moreover, the outcome that would result if we were to allow
the creation of a new cause of action for breach of fiduciary duty
against a physician in these circumstances may be impractical. For
example, physicians often provide services for numerous patients,
many of whom may be covered by different HMOs. In order to
effectively disclose HMO incentives, physicians would have to
remain cognizant at all times of every patient's particular HMO
and that HMO's policies and procedures. See, e.g., M. Hall, A
Theory of Economic Informed Consent, 31 Ga. L. Rev. 511, 525-26 (1997) ("[A] typical primary care physician in a metropolitan
city may have a dozen or more contracts with managed care
networks, while specialists may have several dozen or even a
hundred. It is not feasible to ask physicians to keep track of the
payment incentives and treatment rules for each of these many
different plans, nor is this necessarily good public policy"). If we
were to recognize a breach of fiduciary duty claim in the context
of the case at bar, we fear the effects of such a holding may be
unworkable.
	Plaintiff and the appellate court rely on Current Opinions of
the Council on Ethical and Judicial Affairs of the American
Medical Association (AMA) in support of the argument that
plaintiff can state a cause of action for breach of fiduciary duty
against Dr. Portes for his failure to disclose the Medical Incentive
Fund. Specifically, they rely on Opinion 8.132 entitled "Referral
of Patients: Disclosure of Limitations," which states:
		"Physicians must assure disclosure of any financial
inducements that may tend to limit the diagnostic and
therapeutic alternatives that are offered to patients or that
may tend to limit patients' overall access to care.
Physicians may satisfy this obligation by assuring that the
managed care plan makes adequate disclosure to patients
enrolled in the plan." AMA Council on Ethical and
Judicial Affairs, Current Op. 8.132 (1995-2000).
As previously noted in this opinion, the Illinois legislature
determined that disclosure to patients is to be made by managed
care plans.
	In addition to AMA opinions, plaintiff and the appellate court
also rely on Herdrich v. Pegram, 154 F.3d 362 (7th Cir. 1998),
Shea v. Esensten, 107 F.3d 625 (8th Cir. 1997), and Moore v.
Regents of the University of California, 271 Cal. Rptr. 146, 793 P.2d 479 (1990), to support the establishment of a cause of action
for breach of a fiduciary duty by medical professionals. As
discussed, the United States Supreme Court has reversed Herdrich
and held that, under ERISA, a physician's "mixed" decisions
about HMO eligibility and patient treatment is not a fiduciary
decision. Herdrich, 530 U.S. at ___, 147 L. Ed. 2d  at 186, 120 S. Ct.  at 2158. Shea held that a plaintiff could state a cause of action
against an HMO for breach of fiduciary duty under ERISA for the
HMO's failure to disclose physician incentive schemes. Shea, 107 F.3d  at 629. The Shea court, like the Illinois General Assembly,
placed the burden of disclosing financial incentive plans on the
entity that both creates those plans and is more equipped to make
those disclosures-the HMO. However, the issue of whether an
HMO breaches its fiduciary duty in failing to disclose incentive
schemes is not before us today. As our appellate court pointed out,
both Herdrich, before it was reversed, and Shea "recognize that
patients should be informed of financial arrangements that may
negatively impact their health care." 303 Ill. App. 3d at 808. While
we may agree that patients should be told of financial
considerations which may negatively impact their healthcare, we
will not place the burden of that disclosure on physicians.
	Moreover, plaintiff's reliance on Moore is misplaced. Moore
involved a plaintiff who alleged that his doctor breached his
fiduciary duty when the doctor used portions of the plaintiff's
spleen and other cells, which he recommended be removed, to
conduct research and benefit financially without informing the
plaintiff. Moore, 271 Cal. Rptr.  at 148, 793 P.2d  at 481. The
California appellate court held that the plaintiff could state a cause
of action for either breach of fiduciary duty or for the performance
of medical procedures without informed consent. Moore, 271 Cal. Rptr.  at 150, 793 P.2d  at 485. However, a physician's failure to
disclose HMO incentive plans is significantly unlike the egregious
nature of the alleged behavior at issue in Moore. Further, in
Moore, the plaintiff had no way of discovering the physician's
research plans unless disclosed by his physician. In Illinois, a
patient can obtain information about the relationship and payment
practices between her physician and her HMO by contacting the
HMO.
	Plaintiff also cites numerous cases that allow breach of
fiduciary duty claims against professionals other than physicians.
See Doe v. Roe, 289 Ill. App. 3d 116 (1997); Regnery v. Meyers,
287 Ill. App. 3d 354 (1997); Winston & Strawn v. Nosal, 279 Ill.
App. 3d 231 (1996); Kurtz v. Solomon, 275 Ill. App. 3d 643
(1995); Newton v. Aitken, 260 Ill. App. 3d 717 (1994); Lossman
v. Lossman, 274 Ill. App. 3d 1 (1995); Progressive Land
Developers, Inc. v. Exchange National Bank, 266 Ill. App. 3d 934
(1994); Levy v. Markal Sales Corp., 268 Ill. App. 3d 355 (1994);
In re Estate of Savage, 259 Ill. App. 3d 328 (1994); Glass v.
Burkett, 64 Ill. App. 3d 676 (1978). These cases are inapposite, as
the plaintiffs in those cases did not bring causes of action sounding
in both breach of fiduciary duty and negligence. Thus, the courts
in the cited cases did not determine whether the plaintiffs' injuries
were sufficiently addressed by traditional negligence claims.
	In Coughlin v. SeRine, 154 Ill. App. 3d 510 (1987), on which
plaintiff also relies, the appellate court permitted a plaintiff to
bring a cause of action for both professional malpractice and
breach of fiduciary duty against his attorney. Unlike the case at
bar, however, Illinois courts have long recognized a cause of
action for breach of fiduciary duty by an attorney. Thus, the
Coughlin court was not confronted with the determination of
whether to create a new cause of action. Furthermore, apparently
no argument was raised regarding whether the malpractice and
breach of fiduciary duty claims were duplicative. Consequently,
the Coughlin court engaged in no discussion regarding the
potential duplicative nature of those claims. We therefore do not
find the Coughlin case to be pertinent to our decision today.
	We decline to recognize a new cause of action for breach of
fiduciary duty against a physician for the physician's failure to
disclose HMO incentives in a suit brought against the physician
for medical negligence. We hold that, under the facts in the case
at bar, a breach of fiduciary duty claim is duplicative of a medical
negligence claim. The injuries suffered by plaintiff as a result of
Dr. Portes' medical care are sufficiently addressed by application
of traditional concepts of negligence.
II. Evidence of Financial Incentives at Trial
	The appellate court held that evidence of the Medical
Incentive Fund may be relevant in the event that Dr. Portes
testifies in the medical negligence trial. 303 Ill. App. 3d at 817.
The appellate court noted that, in general, a witness may be cross-examined on issues relating to interest and bias, and found that
"issues concerning Dr. Portes' financial gain go to his credibility."
We agree. Therefore, we hold that evidence of the Medical
Incentive Fund may be relevant if Dr. Portes testifies at trial. The
relevance and admission of such evidence is for the discretion of
the trial court.
CONCLUSION 
	For the foregoing reasons, we hold that plaintiff may not state
a cause of action for breach of fiduciary duty against Dr. Portes.
Therefore, we reverse the appellate court's reinstatement of count
II. The judgment of the circuit court is affirmed, and the cause is
remanded to that court for further proceedings.
Appellate court judgment affirmed in part
and reversed in part;
circuit court judgment affirmed;
cause remanded.
	A complaint against a lawyer for professional malpractice
may be couched in either contract or tort. Collins v. Reynard, 154 Ill. 2d 48, 50 (1992). In accordance with this principle, our
appellate court has recognized legal malpractice claims grounded
in breach of contract, negligence, and breach of fiduciary duty.
Hanumadass v. Coffield, Ungaretti & Harris, 311 Ill. App. 3d 94,
99-100 (1999). Such claims are not mutually exclusive. Recovery
may be sought in the alternative. Collins, 154 Ill. 2d  at 50.
	The same rule should apply here. Although this case involves
medical rather than legal malpractice, that distinction is
insignificant. For purposes of professional malpractice actions,
medical doctors possess no special characteristics warranting
different treatment than we afford lawyers. As with lawyers and
their clients, doctors not only owe their patients a duty of due care.
They also owe them a fiduciary duty. See Petrillo v. Syntex
Laboratories, Inc., 148 Ill. App. 3d 581, 587-88 (1986).
	The right to assert claims for breach of fiduciary duty and
negligence in the same professional malpractice action is not
unfettered. When the same operative facts support a negligence
count and a count for breach of fiduciary duty based on the same
injury to the client, the counts are identical and the fiduciary duty
count should be dismissed as duplicative. See Majumdar v. Lurie,
274 Ill. App. 3d 267, 273-74 (1995); Calhoun v. Rane, 234 Ill.
App. 3d 90, 95 (1992). In this case, however, the negligence and
breach of fiduciary duty counts asserted by plaintiff are not
identical. As the appellate court correctly recognized,
		"It is conceivable that a trier of fact could find both that
Dr. Portes was within the standard of care and therefore
not negligent in relying on the thallium stress test and the
EKG in deciding that an angiogram was not necessary and
also that Dr. Portes did breach his fiduciary duty in not
disclosing his financial incentive arrangement and, as a
proximate result thereof, Neade did not obtain a second
opinion, suffered a massive coronary infarction, and
died." 303 Ill. App. 3d at 814.
	When my colleagues write that "[t]he injuries suffered by
plaintiff as a result of Dr. Portes' medical care are sufficiently
addressed by application of traditional concepts of negligence"
(slip op. at 13-14), it is clear to me that this distinction has been
lost on them. Dr. Portes' failure to disclose that he had a financial
incentive to deny the test recommended by his two associates and
required by plaintiff's husband triggers separate policy
considerations and constitutes an independent wrong.
	Physicians have professional ethical, moral and legal
obligations to provide appropriate medical care to their patients
and should not allow the exercise of their medical judgment to be
corrupted or controlled. Petrovich v. Share Health Plan of Illinois,
Inc., 188 Ill. 2d 17, 45-46 (1999). At a time when HMO's are
playing an ever-increasing role in how patient care is administered,
these obligations are being tested as never before. In response,
AMA guidelines now require physicians to assure disclosure to
patients of any financial inducements that may tend to limit the
diagnostic and therapeutic alternatives that are offered to patients
or that may tend to limit patients' overall access to care. In
addition, according to documentation and deposition testimony in
this case, current standards of care require a physician to divulge
his financial interests in withholding care to a patient so that the
patient can make an informed decision about the quality of care he
is receiving and the physician's motivation in taking care of him.
	In Illinois, the importance of making patients aware of
possible financial conflicts of interest on the part of their
physicians is reflected in the Health Care Worker Self-Referral
Act (225 ILCS 47/1 et seq. (West 1998)). That law imposes
stringent conditions upon when a physician or other health care
worker may refer a patient to another office or group practice in
which the physician or health care worker is an investor. It also
requires the physician or health care worker to disclose to the
patient his investment interest in the other office or group practice
when he or she is not providing the health care service directly.
The importance of making patients aware of possible financial
conflicts of interest is further reflected in the new Managed Care
Reform and Patient Rights Act (215 ILCS 134/1 et seq. (West
Supp. 1999)), enacted during the pendency of this case, which
requires health plans to disclose to enrollees, upon their written
request, a description of the financial relationships between the
health care plan and any health care provider (215 ILCS 134/15(b)
(West Supp. 1999)).
	It is ironic that the majority should invoke the provisions of
the Managed Care Reform and Patient Rights Act to defeat
plaintiff's claim in this case. The Act reflects the General
Assembly's determination that patients have the right "to care
consistent with professional standards of practice to assure quality
nursing and medical practices, to choose the participating
physician responsible for coordinating his or her care, [and] to
receive information concerning his or her condition and proposed
treatment." 215 ILCS 134/5(a)(1) (West Supp. 1999). One way the
Act helps protect this right is by requiring HMO's to disclose the
financial relationships between the health care plan and the health
care providers in the plan. There is nothing in the Act, however,
which suggests that an HMO's duty of disclosure in any way
supplants or supercedes the independent legal and ethical duty
which a physician has to divulge his financial interests in
withholding care to a patient. Indeed, to construe the Act as
excusing physicians from their own disclosure obligations would
actually diminish patients' access to information and thereby
undermine the very purpose of the law.
	Enabling health plan participants to make written requests for
disclosure of the financial relationship between the plan and the
plan providers is important when patients are selecting health
plans and care providers. It is of limited benefit where, as here, a
patient is already in the plan, under the care of a plan provider, and
is facing treatment choices that have immediate and life-threatening consequences. If there is any possibility that the course
of treatment recommended by the care provider may be affected by
the remuneration he stands to receive from a third party, the
patient has the right to know about it and the care provider has the
obligation to make disclosure.
	The physician's duty of disclosure must be self-executing. It
should not depend on whether a patient specifically asks, and it
should certainly not depend on submission of written requests.
Patients facing catastrophic health problems may be physically or
psychologically incapable of making the necessary inquiries. Even
if they are, they may not think to do it. Most people trust their
doctors and would never imagine that their own physician might
be withholding necessary medical care for personal, financial
reasons.
	I am not moved by the majority's concern that requiring
doctors to fulfill their duty of disclosure will be unduly
burdensome. Doctors share generously in the bounty provided by
modern medicine, and there is no reason to believe that they
cannot manage or afford the administrative tools necessary to keep
them fully apprised of the payment incentives affecting a particular
patient's care. Indeed, there is every reason to believe that payment
incentives are one aspect of health care plans that physicians such
as Dr. Portes will have no trouble at all keeping track of.
According to the allegations in plaintiff's complaint, which must
be taken as true (Connick v. Suzuki Motor Co., 174 Ill. 2d 482, 490
(1996)), Dr. Portes was well aware that the referral recommended
by his associates and needed by plaintiff's husband would reduce
the profit he would receive from the health plan. That is exactly
why he refused to make the referral, and it is why plaintiff's
husband is now dead.
	For the foregoing reasons, I would hold that plaintiff should
be allowed to proceed with her claim for breach of fiduciary duty
as well as her claim for negligence. I therefore dissent.