Case Title: Parr v. Rosenthal

Citation: 

Docket Number: SJC-12014

State: massachusetts

Court: Massachusetts Supreme Court

Date: 2016-09-02T00:00:00Z

Document:
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SJC-12014 
 
MICHAEL PARR1 & another2  vs.  DANIEL ROSENTHAL. 
 
 
 
Essex.     April 5, 2016. - September 2, 2016. 
 
Present:  Gants, C.J., Spina, Cordy, Botsford, Duffly, Lenk, & 
Hines, JJ.3 
 
 
Limitations, Statute of.  Medical Malpractice, Statute of 
limitations.  Negligence, Doctor, Medical malpractice. 
 
 
 
 
Civil action commenced in the Superior Court Department on 
March 9, 2009. 
 
 
The case was tried before Thomas R. Murtaugh, J., and a 
motion for a new trial was heard by him. 
 
 
After review by the Appeals Court, the Supreme Judicial 
Court granted leave to obtain further appellate review. 
 
 
 
Myles W. McDonough (James S. Hamrock, Jr., with him) for 
the defendant. 
 
David J. Gallagher for the plaintiffs. 
                                                          
 
1 As parent and next friend of William Parr. 
 
2 Michele Parr, as parent and next friend of William Parr. 
 
 
3 Justice Cordy participated in the deliberation on this 
case and authored his separate opinion prior to his retirement.  
Justices Spina and Duffly participated in the deliberation on 
this case prior to their retirements. 
2 
 
 
 
Annette Gonthier Kiely, Adam R. Satin, & Thomas R. Murphy, 
for Massachusetts Academy of Trial Attorneys, amicus curiae, 
submitted a brief. 
 
John J. Barter, for Professional Liability Foundation, 
Ltd., amicus curiae, submitted a brief. 
 
 
 
GANTS, C.J.  The plaintiffs commenced this medical 
malpractice action against the defendant in the Superior Court 
for his alleged negligence in connection with a "radio frequency 
ablation" (RFA) procedure he performed on the leg of their minor 
son, which caused severe burning and eventually resulted in the 
amputation of the child's leg.  The jury did not reach the issue 
of negligence because they found that, more than three years 
before the plaintiffs filed the action, they knew or reasonably 
should have known that the child had been harmed by the 
defendant's conduct, so the action was barred by the statute of 
limitations for medical malpractice claims. 
 
The plaintiffs contend that the jury should have been 
instructed on the so-called "continuing treatment doctrine" 
applicable to medical malpractice claims, a doctrine that 
heretofore has not been recognized under Massachusetts law.  
Generally speaking, the doctrine states that a cause of action 
does not accrue, and therefore the statute of limitations clock 
does not begin to run, for medical malpractice claims during the 
period that an allegedly negligent physician continues to treat 
the patient for the same or a related condition.  See, e.g., 
3 
 
 
Borgia v. New York, 12 N.Y.2d 151, 156-157 (1962).  We now 
recognize the doctrine under Massachusetts law and hold that the 
statute of limitations for a medical malpractice claim generally 
does not begin to run while the plaintiff and the defendant 
physician continue to have a doctor-patient relationship and the 
plaintiff continues to receive treatment from the physician for 
the same or a related condition.  We also hold that the 
continuing treatment exception to the discovery rule terminates 
once a patient (or the parent or guardian of a minor patient) 
learns that the physician's negligence was the cause of his or 
her injury.  We further hold that, once the allegedly negligent 
physician no longer has any role in treating the plaintiff, the 
continuing treatment doctrine does not apply even if the 
physician had at one time been part of the same "treatment team" 
as the physicians who continue to provide care.  Here, where the 
jury found that the plaintiffs knew or reasonably should have 
known more than three years before commencing suit that they had 
been harmed by the conduct of the defendant, and where the 
defendant's participation in treating the plaintiff ended more 
than three years before the suit was filed, the cause of action 
accrued more than three years before the action was commenced 
and therefore was not timely under the statute of limitations.  
We thus affirm the judgment in favor of the defendant.4 
                                                          
 
 
4 We acknowledge the amicus briefs submitted by the 
4 
 
 
 
Background.  We recite the facts in the light most 
favorable to the plaintiffs.  See Lipchitz v. Raytheon Co., 434 
Mass. 493, 499 (2001).  William Parr was born on September 3, 
1994.5  At birth, he had a large lump at the back of his right 
calf.  Within a few weeks, he was taken by his parents, Michele 
Parr and Michael Parr, to Massachusetts General Hospital (MGH), 
where he was referred to the "sarcoma group" for imaging studies 
and a biopsy.  The sarcoma group is a team of orthopedic 
surgeons, general surgeons, radiation oncologists, medical 
oncologists, and others who treat tumors of the connective 
tissues, including bones, muscles, fat, nerves, and other 
tissues.  The sarcoma group works on an interdisciplinary model.  
The team members meet twice weekly and have "very close 
interdisciplinary relationships." 
Initially, William's lump was diagnosed by the sarcoma 
group as a "hamartoma."6  By January, 2003, when William was 
eight years old, the size of the lump had increased, causing 
                                                                                                                                                                                           
Massachusetts Academy of Trial Attorneys and the Professional 
Liability Foundation, Ltd. 
 
 
5 Because the child and his parents have the same last name, 
we refer to each by his or her first name. 
 
 
6 A "hamartoma" is a benign tumor-like malformation 
resulting from faulty development in an organ and composed of an 
abnormal mixture of tissue elements that develop and grow at the 
same rate as normal elements but are not likely to compress 
adjacent tissue.  See Stedman's Medical Dictionary 849 (28th ed. 
2006). 
5 
 
 
William occasionally to limp.  At that time, Dr. Mark Gebhardt, 
a member of the sarcoma group at MGH, performed a biopsy in 
which he removed pieces of the lump for the pathologist to 
examine.  Gebhardt determined that the lump was engulfing much 
of William's calf muscle and was having an impact on his nerves 
and blood vessels.  At this time, it was determined that the 
lump was a "desmoid tumor."  Desmoid tumors are relatively rare, 
benign tumors but can grow in such a way as to infiltrate normal 
tissue and impair bodily functions. 
 
Soon after the biopsy, Gebhardt left MGH.  William's care 
was assumed by Dr. David Ebb, a pediatric oncologist, and Dr. 
Kevin Raskin, an orthopedic surgeon, both of whom were on the 
staff at MGH and were members of the sarcoma group.  At some 
point prior to November, 2005, Raskin and Ebb proposed and 
scheduled a surgery on William's tumor, which at this point had 
caused abnormality in his gait.  Meanwhile, Michele continued to 
research other options, and she discussed the possibility of RFA 
treatment with Ebb and Raskin.7  After one of the meetings of the 
                                                          
 
7 Radio frequency ablation (RFA) involves the insertion of a 
long probe with expandable heating tines that generate high 
frequency electrical current to burn or "cook" the target, here 
the tumor.  There are a number of limitations to the procedure:  
(1) the "ablation" or burn zone is constrained by the size of 
the device used and the blood flow to the area, limiting the 
ablation to the spherical area immediately surrounding the 
tines; (2) the RFA procedure does not distinguish between a 
targeted tumor and other healthy, critical structures -- it 
burns everything in its reach; and (3) it is impossible to 
6 
 
 
sarcoma group, Raskin and Ebb approached the defendant, Dr. 
Daniel Rosenthal, about the possibility of performing RFA on 
William's desmoid tumor.  Rosenthal was a board certified 
radiologist on the staff at MGH and had been a member of the 
sarcoma group since 1978.  He "invented" RFA, meaning that he 
was the first physician to use RFA to treat a tumor, and was a 
recognized leader in the field.8  Through the sarcoma group, he 
was generally familiar with William's case.  Raskin and Ebb then 
put Michele in touch with Rosenthal.  They told Michele that 
Rosenthal "was the best doctor in the business basically.  He 
was . . . one of the founders of radiofrequency ablation and had 
worked at [MGH] for a long time."  Rosenthal eventually agreed 
                                                                                                                                                                                           
predict precisely the extent of the zone of ablation.  The 
procedure involves the use of a tourniquet to limit the blood 
flow into the area of the procedure. 
 
 
8 Dr. David Ebb testified that he and Dr. Kevin Raskin 
"regularly worked with [Dr. Daniel Rosenthal] in the context of 
[their] delivering care to patients . . . and were both well 
aware that Dr. Rosenthal had been one of the pioneers in 
applying this technique . . . and felt that he was the best 
resource [they] had with whom to confer regarding this option in 
[William's] case."  Raskin testified that, when Michele first 
inquired about the possibility of treating William with RFA, he 
told her, in effect, "[I]t turns out we have . . . the world's 
expert here at MGH who does radiofrequency ablation and maybe we 
can come up with a plan to use radiofrequency ablation to treat 
this tumor."  Raskin further testified that he knew Rosenthal 
"as part of [their] group at MGH."  He continued, "[W]e have 
. . . very close interdisciplinary relationships.  I mean, I 
can't function as an orthopedic oncologist without . . . Dr. 
Rosenthal, the radiology group helping me interpret imaging, or 
the pathologists helping me interpret slides."  He described his 
relationship with Rosenthal and the group as a "very close, very 
active relationship." 
7 
 
 
to perform the procedure and it was presented and approved at 
subsequent sarcoma group meetings.  Rosenthal had never 
performed RFA on a desmoid tumor before performing the procedure 
on William, and as of the date of trial had not performed 
another RFA on a desmoid tumor. 
 
Prior to the procedure, Rosenthal told Michele that the 
procedure was reasonable and could help William.  Michele 
testified that Rosenthal told her that RFA could "kill" the 
tumor, but he did not explain any risks of the procedure.  
Rosenthal said the procedure would be a day surgery, that 
William would come out with "band-aids" at the sites where the 
probe had gone in, and that he would be home by the afternoon. 
 
Michael brought William to MGH on the morning of November 
4, 2005, for the RFA procedure, and Michele arrived soon 
thereafter.  Rosenthal briefly showed Michael and William a 
drawing describing the procedure, demonstrating the location of 
the tumor and other areas he was going to treat.  Michael signed 
a consent form, which listed the risks of the procedure, 
including bleeding, infection, nerve damage, and failure to 
cure.  The form did not disclose any risk of burns to the skin, 
blood vessels, or other vital structures.  Moreover, the risks 
associated with the use of a tourniquet were not mentioned. 
 
Rosenthal completed the first three of his planned four 
ablations when he noticed what he described as "superficial skin 
8 
 
 
blisters" in the area behind William's knee.  At that point, 
despite not having completed all of the planned ablations, 
Rosenthal realized that he had already burned more than the 
entire planned treatment area.  On seeing the burned area behind 
William's knee, Rosenthal then stopped the procedure and called 
two other sarcoma group members, Ebb and Raskin, to the 
operating room.  A decision was made to discontinue the 
procedure. 
 
Ebb explained to Michael and Michele that there had been a 
complication during the procedure, and that William had suffered 
a burn above the tumor site.  Michele testified that she was not 
told the cause of the burn or how serious it was, but was told  
that William "would recover and be fine."  Michael testified 
that he and Michele did not know how serious the burn was at 
first and that he "never knew" how bad the burn was.  Rosenthal 
originally described it to them as a "superficial burn."  Raskin 
referred to the burn as a "superficial blister" in his notes on 
the day of the RFA procedure. 
 
William was admitted to MGH for one week after the RFA 
procedure and was then transferred to Spaulding Rehabilitation 
Hospital (Spaulding) for an additional five weeks.  Rosenthal 
visited William every day during his week-long stay at MGH and 
several more times at Spaulding.  Rosenthal's last note in 
William's medical file, made during a visit on November 7, 2005, 
9 
 
 
states that there was "clear improvement in his nerve function."  
In fact, by that time, the nerves had been irreparably damaged 
from the burn.  The burned area ultimately grew to full 
thickness, creating a very foul smelling, necrotic blackened 
hole in the back of William's knee that spanned the entire area 
of the knee from medial to lateral.  The nerves were destroyed. 
 
When William returned home from Spaulding, he received in-
home physical therapy, and a visiting nurse provided medical 
care.  He also continued to receive care from the sarcoma group.  
The burn did not heal during this period despite efforts 
throughout the winter that were directed by Raskin.  The burn 
eventually became infected, and William was readmitted to MGH in 
February, 2006.  Raskin performed debridements of the burn.  On 
March 19, 2006, after the seventh debridement, it became clear 
that William's leg could not be saved, and his parents were told 
that amputation below the knee was necessary.  On March 20, 
2006, William's leg was amputated below the knee. 
 
About two years later, a second amputation, this one above 
the knee, became necessary because of continued infections, and 
because there was insufficient muscle preserved to enable use of 
a prosthesis or to make the knee functional.  Thus, on March 12, 
2008, Raskin performed an amputation above the knee on William's 
right leg.  According to Rosenthal's testimony at trial, the 
need for the amputations was a direct result of the complication 
10 
 
 
that occurred during the RFA procedure.  Neither Ebb, Raskin, 
nor Rosenthal at any time described to the Parrs what had caused 
the burn and the resulting injuries.  Michael was told that it 
was simply an "anomaly."  The Parrs did not know what had 
happened, despite asking repeatedly.  As Michael testified, "We 
trusted them, we worked with them and we did not know." 
 
Michele and Michael, as parents and next friends of 
William, filed a civil complaint in the Superior Court on March 
9, 2009, alleging malpractice by Rosenthal with respect to the 
RFA procedure performed by him on November 4, 2005.9  The case 
proceeded to a jury trial.  Because, under G. L. c. 231, § 60D, 
a medical malpractice action brought on behalf of a minor who is 
at least six years old must "be commenced within three years 
from the date the cause of action accrues," the defendant argued 
that he was entitled to judgment because the action was not 
timely filed.  At the charge conference and in his proposed jury 
instructions, the plaintiffs' counsel argued that the statute of 
limitations was tolled while William's treatment was continuing.  
Relying on the continuing treatment doctrine, he argued that a 
cause of action for medical malpractice does not accrue until 
                                                          
 
 
9 The action was brought solely on behalf of William; 
neither Michele nor Michael claimed loss of consortium. 
11 
 
 
treatment of a plaintiff by a defendant doctor, or doctors with 
whom he works, has terminated.10 
The judge declined to give such an instruction.  He 
correctly stated that Massachusetts had not yet recognized the 
continuing treatment doctrine.  He further stated that he "would 
suggest" that Massachusetts would not "adopt that theory," and 
that, in any event, the doctrine would not apply to the facts of 
this case.  The judge said the defendant "rendered a very 
specific treatment" and "[t]hat was it"; "[h]e was not involved 
in the treatment of William after that."  In response to 
counsel's argument that the cause of action did not accrue while 
the plaintiff was being treated by the "treatment team" of which 
the defendant was a member, the judge noted that no 
Massachusetts case had taken that position in a medical 
malpractice case. 
                                                          
 
10 The jury instruction proposed by the plaintiffs, which 
quoted the legal malpractice case of Murphy v. Smith, 411 Mass. 
133, 137 (1991), quoting Greene v. Greene, 56 N.Y.2d 86, 94 
(1982), stated: 
 
 
"Further, the law recognizes that, 'a person seeking 
professional assistance has a right to repose confidence in 
the professional's ability and good faith and realistically 
cannot be expected to question and assess the techniques 
employed or the manner in which services are rendered,' 
while he is still being treated for the same injuries.  The 
law recognizes that it is not reasonable to expect a 
patient to sue her doctor while she is being treated by 
him, or doctors with whom he works, while she is being 
treated by them for the same injury.  The [p]laintiff's 
cause of action does not accrue until treatment for the 
injuries has been terminated."  (Footnotes omitted.) 
12 
 
 
 
As to the question whether the claim was timely brought 
within the statute of limitations, the judge instructed the jury 
as follows: 
 
"Ordinarily a personal injury claim must be 
brought within three years of the date the cause of 
action accrues or arises.  Here, this case was 
commenced on March 6, 2009.[11]  The question is whether 
the claim was brought within three years after the 
date on which the cause of action arose.  The general 
rule is that a cause of action accrues on the date of 
the plaintiff's injury[,] in this case, William's 
injury.  However, that rule does not apply where the 
plaintiff did not know or could not reasonably have 
known of the cause of action. . . . [T]he question 
comes down to whether the plaintiffs knew or should 
have known that William Parr had been harmed to an 
appreciable or not insignificant extent by Dr. 
Rosenthal's conduct." 
 
The judge also explained the meaning of "should have known" 
in this context: 
 
"An action for medical malpractice accrues when a 
reasonably prudent person in the plaintiff's position 
reacting to any suspicious circumstances for which 
they might have been aware should have discovered that 
his medical care given by the physician may have 
caused . . . William appreciable or not insignificant 
injury or harm.  Certainty of causation is not 
required.  Rather, notice of likely cause is 
sufficient to start the statute running[,] imposing on 
the potential litigant the duty to discover from 
legal, scientific and medical communities whether a 
theory of causation supports a legal claim." 
 
                                                          
 
11 The complaint was actually filed on March 9, 2009, but no 
counsel objected to the reference to March 6. 
12 The 
limitation and repose periods for medical malpractice claims 
brought on behalf of adults, established by G. L. c. 260, § 4, 
are essentially identical.  Section 4 provides in relevant part: 
13 
 
 
Plaintiffs' counsel timely objected to the judge's decision not 
to give a continuing treatment instruction regarding the statute 
of limitations. 
 
The jury answered "yes" to the first special verdict 
question:  "Did the plaintiffs know or should they reasonably 
have known prior [to] March 6th, 2006, that they had been . . . 
harmed by the conduct of the defendant?"  Because they answered 
"yes" to this question, they did not reach the other questions, 
including whether the defendant was negligent and, if so, 
whether his negligence was a substantial contributing factor in 
causing William's injury.  Judgment entered for the defendant.  
The plaintiffs moved for a new trial, claiming that the judge 
erred by failing to furnish the jury with the continuing 
treatment instruction.  The judge denied the motion.  The 
plaintiffs appealed from the judge's decision not to give the 
continuing treatment instruction, and from the denial of their 
motion for a new trial. 
 
The Appeals Court reversed the judgment and remanded the 
case for a new trial.  Parr v. Rosenthal, 87 Mass. App. Ct. 787 
(2015).  Relying by analogy on this court's adoption of the 
"continuing representation" doctrine in legal malpractice cases, 
see, e.g., Murphy v. Smith, 411 Mass. 133, 137 (1991), the 
Appeals Court recognized the "continuing treatment" doctrine in 
medical malpractice cases.  The court held that the limitations 
14 
 
 
period does not begin to run during the continuing treatment of 
a patient for the same injury on which the action for medical 
malpractice is based.  See Parr, supra at 788, 792-793.  The 
court also declared that the continuing treatment doctrine "will 
toll the statute of limitations so long as the patient remains 
in continuous treatment for the injury by the same physician or 
group, or under the general control of that physician or group, 
subject to the statute of repose."  Id. at 797. 
 
In cases alleging legal malpractice, the statute of 
limitations, although tolled under the continuing representation 
doctrine, nevertheless begins to run once a client acquires 
actual knowledge that he or she has suffered appreciable harm as 
a result of the attorney's conduct.  See, e.g., Lyons v. Nutt, 
436 Mass. 244, 249-250 (2002).  The Appeals Court, however, held 
that in medical malpractice cases "actual knowledge should not 
bar application of the continuing treatment doctrine so long as 
the patient is continuing treatment in good faith and not solely 
to allow more time to develop their malpractice case."  Parr, 
supra at 798.  We granted the defendant's application for 
further appellate review. 
 
Discussion.  To state a claim for medical malpractice, a 
plaintiff must demonstrate that (1) the plaintiff suffered harm; 
(2) the harm was caused by the defendant physician's conduct; 
and (3) the defendant physician was negligent, which in medical 
15 
 
 
malpractice cases means that the physician committed a breach of 
the "standard of care and skill of the average member of the 
profession" practicing in his or her specialty.  See Bradford v. 
Baystate Med. Ctr., 415 Mass. 202, 206-208 (1993), quoting Brune 
v. Belinkoff, 354 Mass. 102, 109 (1968).  Where a defendant 
raises the statute of limitations as an affirmative defense, the 
plaintiff also bears the burden of proving that the action was 
timely commenced.  See Franklin v. Albert, 381 Mass. 611, 619 
(1980).  The limitation and repose periods for medical 
malpractice claims brought on behalf of minors over the age of 
six are established by G. L. c. 231, § 60D, which provides in 
relevant part: 
 
"[A]ny claim by a minor against a health care 
provider stemming from professional services or health 
care rendered, whether in contract or tort, based on 
an alleged act, omission or neglect shall be commenced 
within three years from the date the cause of action 
accrues . . . , but in no event shall such action be 
commenced more than seven years after occurrence of 
the act or omission which is the alleged cause of the 
injury upon which such action is based except where 
the action is based upon the leaving of a foreign 
object in the body."12 
                                                          
 
 
12 The limitation and repose periods for medical malpractice 
claims brought on behalf of adults, established by G. L. c. 260, 
§ 4, are essentially identical.  Section 4 provides in relevant 
part: 
 
 
"Actions of contract or tort for malpractice, 
error or mistake against physicians [and] surgeons . . 
. shall be commenced only within three years after the 
cause of action accrues, but in no event shall any 
such action be commenced more than seven years after 
occurrence of the act or omission which is the alleged 
16 
 
 
 
 
The statute of repose is not at issue in this case.  The 
plaintiffs' claim clearly was brought within seven years of 
William's RFA treatment.  The defendant does not claim 
otherwise.  The key question is whether the claim was timely 
brought within the statute of limitations, i.e., within three 
years of when the cause of action accrued. 
 
A statute of limitations typically prescribes the time 
period when an action must be commenced after the cause of 
action "accrues."  The statute sets the limitations period, but 
in the absence of explicit legislative direction, it is our 
common law that determines when a cause of action accrues, and 
hence when the limitations period actually begins to run.  See 
Franklin, 381 Mass. at 617 ("Absent explicit legislative 
direction, the determination of when a cause of action accrues, 
causing the statute of limitations to run, has long been the 
product of judicial interpretation in this Commonwealth").  In 
Franklin, supra at 619, we held that the discovery rule applies 
to the statute of limitations for medical malpractice claims.13  
                                                                                                                                                                                           
cause of the injury upon which such action is based 
except where the action is based upon the leaving of a 
foreign object in the body." 
 
13 By the time we decided Franklin v. Albert, 381 Mass. 611, 
619 (1980), we had already applied the discovery rule to other 
causes of action.  See, e.g., Friedman v. Jablonski, 371 Mass. 
482, 485 (1976) (fraudulent misrepresentations in sale of real 
estate); Hendrickson v. Sears, 365 Mass. 83, 83-84 (1974) (legal 
malpractice). 
17 
 
 
Under the discovery rule, medical malpractice claims "accrue" 
"when the plaintiff learns, or reasonably should have learned, 
that he has been harmed by the defendant's conduct."  Id.  "In 
determining whether a party has sufficient notice of causation, 
our inquiry is whether, based on the information available to 
the plaintiff, a reasonably prudent person in the plaintiff's 
position should have discovered the cause of his or her 
injuries."  Lindsay v. Romano, 427 Mass. 771, 774 (1998), 
quoting McGuinness v. Cotter, 412 Mass. 617, 628 (1992).  "We do 
not require that a plaintiff have notice of a breach of a duty 
before a cause of action may accrue . . . ."  Bowen v. Eli Lilly 
& Co., 408 Mass. 204, 208 (1990).  See Lindsay, supra ("It is 
not necessary that the plaintiff have notice that the defendant 
was actually responsible for the injury, only that she have 
knowledge or sufficient notice that the medical care given by 
the defendant may have caused the injury").  In essence, under 
our common law, once a patient knows or reasonably should know 
that he or she has suffered harm and that the harm was caused by 
the physician's conduct, the statute of limitations clock starts 
to run, and the patient then has three years to discover whether 
the physician committed a breach of the standard of care and 
whether the theory of causation is supported by the evidence, 
and, if so, to commence a civil suit.  See Bowen, supra at 208, 
quoting Fidler v. Eastman Kodak Co., 714 F.2d 192, 199 (1st Cir. 
18 
 
 
1983) ("Thus on notice, the potential litigant has the duty to 
discover from the legal, scientific, and medical communities 
whether the theory of causation is supportable and whether it 
supports a legal claim"). 
 
1.  Continuing treatment doctrine.  The plaintiffs argue 
that Massachusetts should recognize the continuing treatment 
doctrine, which provides that a cause of action does not accrue 
while the patient is continuing to receive treatment for the 
same or related injury or illness from the same physician who 
allegedly caused the patient harm.  See Otto v. National Inst. 
of Health, 815 F.2d 985, 988 (4th Cir. 1987), and cases cited 
(in claims brought under Federal Tort Claims Act, "where there 
has been a course of continuous medical treatment, a claim may 
not accrue until the end of that course of treatment, if the 
treatment has been for the same illness or injury out of which 
the claim for medical malpractice arose").  See also Borgia, 12 
N.Y.2d at 155-156.  The rationale for the doctrine appears to be 
two-fold.  First, a patient who continues a physician-patient 
relationship impliedly continues to have trust and confidence in 
the physician, and this trust and confidence put "the patient at 
a disadvantage to question the doctor's techniques," Barrella v. 
Richmond Mem. Hosp., 88 A.D.2d 379, 384 (N.Y. 1982), and impair 
"the patient's ability to make an informed judgment as to 
negligent treatment."  Harrison v. Valentini, 184 S.W.3d 521, 
19 
 
 
525 (Ky. 2005).  See Otto, supra ("The continuous treatment 
doctrine is based on a patient's right to place trust and 
confidence in his physician. . . .  [T]he patient is excused 
from challenging the quality of care being rendered until the 
confidential relationship terminates").  Second, where there is 
a poor medical result from a physician's treatment or procedure, 
a patient is entitled to allow the physician an adequate 
opportunity to remedy or mitigate the poor result without 
needing to risk interruption of that course of treatment by 
exploring whether the poor result arose from that physician's 
negligence.  See id. ("the doctrine permits a wronged patient to 
benefit from his physician's corrective efforts without the 
disruption of a malpractice action"); Barrella, supra (patient 
is entitled "to rely upon the doctor's professional skill 
without the necessity of interrupting a continuing course of 
treatment by instituting suit"). 
 
In Murphy v. Smith, 411 Mass. 133, 137 (1991), we adopted 
an analogous "continuing representation" rule for legal 
malpractice claims.  The plaintiffs in that case had received a 
letter from their neighbors' attorney in 1983, informing them 
that they did not have good title to property they had 
purchased.  Id. at 135.  The plaintiffs then contacted the 
defendant, the bank's attorney who had certified good record 
title when they purchased the property.  Id.  The defendant 
20 
 
 
assured them that the letter "did not present a cause for 
concern and that he would take care of it."  Id. at 137.  The 
court determined that the defendant's legal representation of 
the plaintiffs began with this assurance, and ended in 1985, 
when they retained a new attorney.  Id. at 135, 137.  They 
commenced a legal malpractice action against the defendant in 
1987.  Id. at 135.  If the discovery rule applied without 
exception, the three-year statute of limitations would have 
begun to run at the time the plaintiffs received the letter from 
their neighbors' attorney, i.e., when they were put on notice of 
the alleged defect in their title, and their malpractice claim 
against the defendant would have been time barred. 
 
The court in Murphy adopted the continuing representation 
doctrine as an exception to the discovery rule, holding that the 
doctrine "tolls the statute of limitations in legal malpractice 
actions where the attorney in question continues to represent 
the plaintiff's interests in the matter in question."  Id. at 
137.  The statute of limitations in that case thus did not begin 
to run until 1985, when the defendant's representation of the 
plaintiffs ended.  The continuing representation doctrine 
"recognizes that a person seeking professional assistance has a 
right to repose confidence in the professional's ability and 
good faith, and realistically cannot be expected to question and 
assess the techniques employed or the manner in which the 
21 
 
 
services are rendered."  Id., quoting Cantu v. Saint Paul Cos., 
401 Mass. 53, 58 (1987). 
 
The reasoning we embraced in Murphy, supra, in adopting the 
continuing representation exception to the discovery rule in 
legal malpractice claims also justifies the adoption of a 
continuing treatment exception to the discovery rule in medical 
malpractice claims.  Under the discovery rule, we ordinarily 
start the clock when the patient knows or has reason to know 
that he or she has been harmed by the physician's conduct; we 
consider such knowledge or reason to know sufficient to trigger 
the patient's "duty to discover" within the three-year 
limitations period whether the physician committed a breach of 
the standard of care and was the legal cause of the patient's 
injury.  See Bowen, 408 Mass. at 208-210.  However, while that 
physician continues to treat the patient for the same or related 
injury or illness, the physician's patient, like an attorney's 
client, "realistically cannot be expected to question and assess 
the techniques employed or the manner in which the services are 
rendered."  Murphy, supra at 137.  Just as we recognize that a 
represented party is entitled to retain confidence in his or her 
legal counsel's "ability and good faith" while the 
representation continues, so, too, do we recognize that a 
patient is entitled to retain confidence in his or her 
physician's ability and good faith while continuing treatment 
22 
 
 
with that physician.  The legal client is disadvantaged in 
learning whether his or her attorney has committed a breach of 
the standard of care while that attorney continues to represent 
the client, and so, too, is a patient disadvantaged in learning 
whether a physician has committed a breach of the standard of 
care while the physician continues to treat the patient.  And 
just as a wronged client is permitted to benefit from his or her 
attorney's efforts to correct a problem without the disruption 
of exploring the viability of a legal malpractice action, so, 
too, is a patient permitted that same benefit without the 
disruption of exploring the viability of a medical malpractice 
action. 
 
Moreover, there is no "explicit legislative direction" that 
precludes us from recognizing a continuing treatment exception 
in determining when a medical malpractice cause of action 
accrues.  See Franklin, 381 Mass. at 617.  As the Appeals Court 
correctly noted, the Legislature used almost identical language 
to describe the limitations period for medical malpractice 
claims and for legal malpractice claims.  See Parr, 87 Mass. 
App. Ct. at 793.  Compare G. L. c. 231, § 60D (medical 
malpractice claim by minor who is at least six years old "shall 
be commenced within three years from the date the cause of 
action accrues"), and G. L. c. 260, § 4, second par. (medical 
malpractice claim by adult "shall be commenced only within three 
23 
 
 
years after the cause of action accrues"), with G. L. c. 260, 
§ 4, first par. (legal malpractice claim "shall be commenced 
only within three years next after the cause of action 
accrues").  See generally Harlfinger v. Martin, 435 Mass. 38, 49 
(2001) (noting that discovery rule principles applicable to 
other types of tort claims also applied to medical malpractice 
claims).  The only differences in the language of the statutes 
are slight and insignificant.  Given the nearly identical 
wording of the provisions, there is no reason to conclude that 
our interpretation of when a cause of action "accrues" in legal 
malpractice cases should not have its analog in medical 
malpractice claims. 
 
The defendant argues that the adoption of the continuing 
treatment doctrine would constitute "improper judicial 
legislation," urging us to infer from the absence of legislation 
on the doctrine that the Legislature has rejected it.  The 
defendant points to nothing in the record of the Legislature, 
however, that suggests that its silence on the subject reflects 
a conscious choice to reject the continuing treatment doctrine.  
We decline to interpret the absence of legislative action as an 
affirmative rejection of the doctrine that bars us from adopting 
the continuing treatment doctrine as a common-law interpretation 
24 
 
 
of when a cause of action "accrues" in a medical malpractice 
case.14 
 
Our adoption of the continuing treatment doctrine does not 
affect the statute of repose that applies to medical malpractice 
claims, which provides that "in no event shall such action be 
commenced more than seven years after occurrence of the act or 
omission which is the alleged cause of the injury upon which 
such action is based except where the action is based upon the 
leaving of a foreign object in the body."  G. L. c. 231, § 60D.  
The effect of a statute of repose "is to place an absolute time 
limit on the liability of those within [its] protection and to 
abolish a plaintiff's cause of action thereafter, even if the 
plaintiff's injury does not occur, or is not discovered, until 
after the statute's time limit has expired" (citation omitted).  
Rudenauer v. Zafiropoulos, 445 Mass. 353, 357 (2005).  
                                                          
 
 
14  The defendant has not identified any proposed bill to 
create a continuing treatment exception to the discovery rule in 
medical malpractice cases that the Legislature failed to enact.  
But even if the Legislature had, we would not necessarily 
interpret its failure to enact such legislation as demonstrating 
an affirmative legislative rejection of such an exception.  In 
Franklin v. Albert, 381 Mass. 611, 617 (1980), we noted that 
several bills that would have amended G. L. c. 260, § 4, to 
include a discovery rule had been proposed and rejected by the 
Legislature, but we declined to "read the failure to enact these 
bills as necessarily disapproving, in principle, a discovery 
rule."  We recognized that, "[t]he practicalities of the 
legislative process furnish many reasons for the lack of success 
of a measure other than legislative dislike for the principle 
involved in the legislation."  Id. at 615-616, quoting Berry v. 
Branner, 245 Or. 307, 311 (1966). 
25 
 
 
Therefore, in this case, the plaintiffs' cause of action would 
have been barred by the statute of repose had it been brought 
more than seven years after November 4, 2005, the date of the 
RFA procedure, even if the cause of action had yet to accrue 
under the continuing treatment doctrine.15,16 
                                                          
 
 
15 The defendant contends, in a single short paragraph at 
the end of his brief, that if we adopt the continuing treatment 
doctrine we should only do so prospectively because it would be 
"a drastic change" in the current law on accrual of causes of 
action.  Assuming that this constitutes adequate appellate 
argument, we disagree.  As the foregoing discussion shows, the 
continuing treatment doctrine in medical malpractice cases is a 
logical and foreseeable application of the same basic principles 
that underlie the continuing representation doctrine in legal 
malpractice cases, which has been in effect at least twenty-five 
years.  See Murphy, 411 Mass. at 137.  There is nothing 
"drastic" or radically new about it. 
 
 
16 The dissent claims that our recognition of the continuing 
treatment doctrine "intrudes into a critically important sphere 
of health care policymaking and makes [our] own preferred policy 
judgment without any inkling of the effect it might have on the 
cost of health care in Massachusetts, a matter of acute concern 
to the executive and legislative branches of government."  Post 
at     .  This criticism rests on three fallacies.  First, the 
dissent assumes that the continuing treatment doctrine will 
dramatically increase the cost of health care by significantly 
increasing the cost of medical malpractice insurance to health 
care professionals.  Some perspective is in order.  The 
continuing treatment doctrine will permit adjudication on the 
merits of medical malpractice claims that were filed more than 
three years after a plaintiff learned, or reasonably should have 
learned, that he or she has been harmed by a physician's 
conduct, but fewer than seven years after the occurrence of the 
allegedly negligent act, where the patient continues to be 
treated for the same or related condition by the allegedly 
negligent physician.  There is no reason to believe, let alone 
adequate factual information in the record to support a belief, 
that adoption of the doctrine will affect enough claims to have 
any meaningful impact on the cost of medical malpractice 
insurance. 
26 
 
 
 
2.  Effect of actual knowledge on continuing treatment 
doctrine.  In Lyons v. Nutt, 436 Mass. 244, 250 (2002), we held 
that the continuing representation exception to the discovery 
rule in a legal malpractice case terminates once "the client 
actually knows that he suffered appreciable harm as a result of 
his attorney's conduct."  We reasoned that once "the client has 
such knowledge, then there is no 'innocent reliance which the 
continued representation doctrine seeks to protect.'"  Id., 
quoting Cantu, 401 Mass. at 58.  The defendant urges us to apply 
                                                                                                                                                                                           
 
 
Second, the dissent assumes, without any factual basis, 
that the Legislature prefers that the few patients who would be 
affected by the continuing treatment doctrine should be denied 
the opportunity to receive any compensation for their 
physician's negligence in order to avoid the remote possibility 
that adoption of the continuing treatment doctrine would 
significantly affect the cost of medical malpractice insurance. 
 
 
Third, although the Legislature has consistently remained 
silent as to when a cause of action accrues, leaving that to be 
determined by the courts under the common law, and although the 
dissent recognizes that we made clear in Franklin, 381 Mass. at 
617, that "[a]bsent explicit legislative direction, the 
determination of when a cause of action accrues, causing the 
statute of limitations to run, has long been the product of 
judicial interpretation in this Commonwealth," the dissent 
assumes that we can and should infer from the Legislature's 
silence that it has made a "policy judgment" to reject the 
continuing treatment doctrine.  To adopt the dissent's inference 
from silence would contradict this statement in Franklin and 
invite all the confusion that arises from an inference based on 
legislative silence.  Moreover, if any inference is to be made 
from silence, we can infer from the absence of "explicit 
legislative direction" as to when a cause of action accrues that 
the Legislature has been content to leave this matter to 
judicial interpretation, and has instead barred older claims 
only through enactment of a statute of repose. 
27 
 
 
an analogous rule for the continuing treatment exception in 
medical malpractice cases. 
 
In deciding whether to adopt this "actual knowledge" rule, 
we first consider the logic and purpose behind it.  We declared 
in Lyons, 436 Mass. at 247, quoting Williams v. Ely, 423 Mass. 
467, 473 (1996), that "[t]he statute of limitations applicable 
to a legal malpractice claim begins to run when a client 'knows 
or reasonably should know that he or she has sustained 
appreciable harm as a result of the lawyer's conduct.' . . .  
This is the so-called discovery rule."  The consequence of the 
termination rule in Lyons is that, even where the client 
continues to be represented by the attorney, the statute of 
limitations clock for legal malpractice claims begins when a 
client actually knows that he or she has sustained appreciable 
harm as a result of the lawyer's conduct.  If a client 
reasonably should know that the attorney has caused the client 
appreciable harm, but does not actually know it, the continuing 
representation rule continues to apply. 
 
However, in the practice of law, actual knowledge that an 
attorney caused a client appreciable harm generally means actual 
knowledge that the attorney committed legal malpractice.  
Indeed, in Lyons, 436 Mass. at 247-248, 251, we affirmed the 
judge's ruling that the continuing representation exception did 
not apply after the client realized that his law firm "didn't 
28 
 
 
know what they were doing" once the offeror "walked away from 
the deal."  See Hendrickson v. Sears, 365 Mass. 83, 91 (1974) 
("A client's cause of action against an attorney for negligent 
certification of title to real estate does not 'accrue' . . . 
until the misrepresentation is discovered or should reasonably 
have been discovered, whichever first occurs . . ."). 
 
But with medical malpractice, a patient's actual knowledge 
that the physician has caused the patient appreciable harm does 
not necessarily mean that the patient knows that the physician 
was negligent, because every medical procedure carries with it a 
risk of complications that may occur naturally without any 
breach of the standard of care by the physician.  The instant 
case is a classic example:  there was no question that the 
defendant's RFA procedure caused appreciable harm to William, 
but actual knowledge of that fact shed little light on whether 
the harm arose from a mere complication or from the defendant's  
breach of the standard of care.  Therefore, in contrast with an 
attorney's client, it is simply incorrect to say that, once a 
physician's patient knows that the physician has caused the 
patient appreciable harm, there can be no "innocent reliance" 
that the continuing treatment doctrine seeks to protect.  A 
patient who continues under the care of the same physician will 
still have the same challenges in learning whether the harm the 
patient suffered from the physician's treatment arose from the 
29 
 
 
physician's negligence.  Thus, we conclude that the continuing 
treatment exception to the discovery rule terminates only when 
the plaintiff has actual knowledge that his or her treating 
physician's negligence has caused the patient's appreciable 
harm, because it is only then that there can no longer be the 
kind of "innocent reliance" that the continuing treatment 
doctrine seeks to protect.  Once a patient learns that the 
physician's negligence was the cause of his or her injury, the 
patient has acquired sufficient information to initiate 
litigation, and there is no longer adequate reason to continue 
to toll the statute of limitations.17 
                                                          
 
 
17 The Appeals Court held that the continuing treatment 
doctrine does not end, and continues to apply, even if the 
patient becomes aware of the physician's negligence, stating 
that there is a "compelling reason to continue to protect the 
physician-patient relationship even after the plaintiff arguably 
has actual knowledge.  The patient could in 'good faith . . . 
know[] that the physician has rendered poor treatment, but 
continue[] treatment in an effort to allow the physician to 
correct any consequences of the poor treatment.'"  Parr v. 
Rosenthal, 87 Mass. App. Ct. 787, 798 (2015), quoting Harrison 
v. Valentini, 184 S.W.3d 521, 525 (Ky. 2005).  We decline to 
place so great an emphasis on the protection of the physician-
patient relationship once the patient has actually learned of 
the physician's negligence.  Where a physician has acted 
negligently in the patient's treatment, the benefit of promoting 
the continuation of that relationship is questionable.  Faced 
with the prospect of the patient suing for malpractice, the 
physician has competing interests -- on one hand to see that the 
patient gets the best treatment, and on the other hand to 
protect his or her own interest by avoiding exposure to 
liability.  While there may be circumstances where the 
physician's unique familiarity with the patient's medical 
history enables the physician to treat the patient's condition 
most effectively, there may well be others where the physician's 
30 
 
 
 
To be clear, by declaring that the tolling of the statute 
of limitations ends under the continuing treatment doctrine only 
when a plaintiff obtains actual knowledge of a physician's 
negligence, we are not revising the discovery rule in medical 
malpractice.  Where the continuing treatment doctrine does not 
apply, the statute of limitations clock begins to run on a 
medical malpractice claim when the plaintiff learns, or 
reasonably should have learned, that he or she has been harmed 
by the defendant's conduct.  Franklin, 381 Mass. at 619.  Where 
the continuing treatment doctrine does apply and, but for the 
application of the doctrine the statute of limitations clock 
would have started under the discovery rule, the tolling arising 
from the doctrine ends once the plaintiff has actual knowledge 
that the physician's negligence was the cause of his or her 
injury. 
 
3.  Applicability of continuing treatment doctrine during 
treatment by physicians other than the defendant.  In this case, 
there is no evidence that Rosenthal continued to treat William 
at any point after William returned home from Spaulding in 
December, 2005.  If the continuing treatment doctrine applies to 
Rosenthal's treatment only, then the doctrine would not toll the 
statute of limitations period long enough to render the 
                                                                                                                                                                                           
negligence is indicative of inferior knowledge or skill that 
will continue to adversely affect the patient's recovery. 
31 
 
 
plaintiffs' action timely.  The question becomes whether the 
doctrine continued to apply, and continued to toll the statute 
of limitations for a claim against Rosenthal, for the additional 
period that Raskin and Ebb treated William thereafter, as they 
continued to try to remedy the damage done during the RFA 
procedure. 
The plaintiffs in their proposed jury instruction claimed 
that the continuing treatment doctrine applies during the 
ongoing treatment by a defendant physician "or doctors with whom 
he works."  See note 8, supra.  On appeal, the plaintiffs 
contend that it applies to medical personnel who were (1) in 
some "relevant association with the [initial treating] 
physician," Kelly v. State, 110 A.D.2d 1062, 1063 (N.Y. 1985) 
(Hancock, J.P., dissenting); or (2) "part of the same team," 
Tausch v. Riverview Health Inst. L.L.C., 187 Ohio App. 3d 173, 
182 (2010).  The Appeals Court recognized that "[t]he case law 
in other jurisdictions does not clearly establish a single rule 
for when treatment by an associated doctor can be imputed to the 
alleged negligent doctor."  Parr, 87 Mass. App. Ct. at 794, 
citing Tolliver v. United States, 831 F. Supp. 558, 560 (S.D. W. 
Va. 1993).  See Parr, supra at 795 n.20, and cases cited.  The 
court adopted a variation of the plaintiffs' argument and held 
that, "[o]n retrial, if the jury conclude that William was a 
group patient of all three doctors and not an individual patient 
32 
 
 
of Drs. Raskin and Ebb, or that the defendant was still 
providing input to Drs. Raskin and Ebb on William's care as part 
of the group prior to the amputation, then their continuing 
treatment for the burn can be imputed to the defendant."  Id. at 
795-796. 
 
We agree that the continuing treatment doctrine would apply 
where an allegedly negligent physician continues to supervise, 
advise, or consult with other physicians who are treating the 
patient for the same or a related injury.  See Otto, 815 F.2d at 
989 (in medical malpractice case where National Institute of 
Health [NIH] was sole defendant, continuing treatment doctrine 
applied where "additional treatment was rendered at the advice 
and under the direction of the NIH physicians"); Stephenson v. 
United States, 147 F. Supp. 2d 1106, 1112 (D.N.M. 2001) 
(continuing treatment doctrine applied where negligent primary 
care physician had "continued direct involvement in evaluating 
[the patient]'s progress" and exercised "control over the 
treatment of [the patient] by the other health-care providers"); 
Echols v. Keeler, 735 P.2d 730, 732 (Wyo. 1987) (continuing care 
doctrine did not apply where allegedly negligent doctor did "not 
continue as [the patient's] doctor nor was he associated with or 
engaged in assisting the doctors thereafter treating [the 
patient]").  There was no evidence here, however, that after 
December, 2005, Rosenthal supervised the treatment of William, 
33 
 
 
or advised or consulted with Raskin and Ebb regarding their 
treatment of him.  Consequently, for the plaintiffs' medical 
malpractice cause of action to be timely, the continuing 
treatment doctrine would need to apply to the period following 
the surgery in which William was being treated by Raskin and Ebb 
alone. 
 
We need not determine here whether to follow the case law 
in other jurisdictions that have applied the continuing 
treatment doctrine to the continuing care of other physicians in 
the same medical group partnership or medical clinic where a 
patient is considered by the physicians and the patient to be a 
patient of the group or clinic rather than of an individual 
physician.  See Offerdahl v. University of Minn. Hosps. & 
Clinics, 426 N.W.2d 425, 428 (Minn. 1988); Watkins v. Fromm, 108 
A.D.2d 233, 239 (N.Y. 1985).  In Offerdahl, supra, the plaintiff 
was a student at the University of Minnesota who "did not seek 
treatment from any particular University physician but employed 
the University clinic generally as her physician."  The Supreme 
Court of Minnesota held that although the claim was based upon 
negligence by a particular physician of the clinic, "under these 
unique facts where the patient sought treatment from a clinic as 
a whole rather than an individual physician, the treatment of 
the clinic as a whole, rather than that of the individual 
physician alleged to have committed the act of malpractice, is 
34 
 
 
relevant for purposes of determining when treatment terminated 
and the statute of limitations began to run."  Id.  Similarly, 
in Watkins, supra at 234-235, the Appellate Division of the 
Supreme Court of New York held that the continuing treatment 
doctrine tolled the statute of limitations where ongoing 
treatment was provided by members of the negligent physician's 
medical group because, according to deposition testimony, the 
plaintiff "was considered to be a patient of the entire medical 
group, rather than of any one of the individual doctors, and 
that it was the practice of the defendant doctors to discuss, as 
a group, the diagnosis and treatment of all of the patients 
under their care."  Those factual circumstances are not 
presented here.  There is no evidence in the record that William 
was treated as a patient of the sarcoma group rather than of the 
particular physicians providing treatment, that the physicians 
in the group discussed the diagnosis or treatment of all their 
patients with the group, or that William's parents believed him 
to be a patient of the group rather than of individual 
physicians. 
 
We have considered whether the reasons that underlie the 
continuing treatment doctrine justify the application of the 
doctrine where the allegedly negligent physician and the 
physician who continues to treat the patient once were together 
part of a patient's "treatment team."  We recognize that, in 
35 
 
 
these circumstances, there is a risk that a patient's continued 
trust and confidence in the physician providing continuing care 
might put the patient at a disadvantage in making an informed 
judgment as to whether a former team member provided negligent 
treatment, especially where the physician providing the 
continuing care effectively brought the allegedly negligent 
physician onto the team.  We also recognize that there is a risk 
that, if a plaintiff were to contemplate a medical malpractice 
action against a former team member, the plaintiff might 
reasonably fear that exploring an action against that physician 
would interrupt or otherwise interfere with the patient's 
continuing treatment with other members of the team because of 
their respect for and close connection with that physician. 
 
We are reluctant, however, to extend the continuing 
treatment doctrine to a "treatment team" for two reasons.  
First, tolling the statute of limitations while the plaintiff 
continues to be treated by a "treatment team" that once included 
the allegedly negligent physician poses the risk that what was 
intended to be a narrow exception may be interpreted so broadly 
as to devour the discovery rule in medical malpractice cases.  
Second, given the multitude of different ways in which patients 
receive medical treatment in this Commonwealth, it is difficult 
to define with precision a patient's "treatment team."  The 
absence of a precise definition means not only that it would be 
36 
 
 
difficult at trial to instruct a jury regarding the statute of 
limitations but, more importantly, it would be difficult to 
determine whether a case should be dismissed before trial on 
statute of limitations grounds.  The clarity and precision of a 
limitations period is important to the interests of justice, 
because it enables untimely filed cases to be dismissed before 
trial, thus sparing all parties the needless time, expense, and 
burden of a trial where the jury will never reach an 
adjudication on the merits. 
 
Because, having balanced the competing considerations, we 
are unwilling to apply the continuing treatment doctrine to the 
plaintiff's continued treatment by a "treatment team" that once 
included the defendant, the doctrine does not apply in this case 
after December, 2005.  And without the tolling of the statute of 
limitations beyond that date under the continuing treatment 
doctrine, the plaintiffs' medical malpractice claim was not 
timely filed. 
 
Conclusion.  We affirm the judgment in favor of the 
defendant and the order denying the plaintiffs' motion for a new 
trial. 
 
 
 
 
 
 
 
So ordered. 
 
 
 
 
CORDY, J. (dissenting in part).  The court's decision today 
fails to consider several factors that strongly militate against 
adopting a continuing treatment exception to our settled 
discovery rule for medical malpractice claims.  Instead, the 
court imprudently intrudes into a critically important sphere of 
health care policymaking and makes its own preferred policy 
judgment without any inkling of the effect it might have on the 
cost of health care in Massachusetts, a matter of acute concern 
to the executive and legislative branches of government.  These 
branches are far better equipped to balance the benefits of a 
prolonged statute of limitations with the cost and access issues 
it implicates.  Just because the court can act to change the law 
does not mean that it should.  Therefore, I respectfully dissent 
from the court's adoption of the continuing treatment doctrine 
for medical malpractice cases. 
 
For nearly forty years, our law has been clear:  a cause of 
action for medical malpractice "accrue[s] when the plaintiff 
learns, or reasonably should have learned, that he has been 
harmed by the defendant's conduct."  Franklin v. Albert, 381 
Mass. 611, 619 (1980).  See G. L. c. 231, § 60D.  Once the harm 
and its causal relationship to acts of the physician is known or 
reasonably should have been learned, the statute of limitations 
clock starts to run, and the patient has three years to 
2 
 
 
determine whether to file suit.  See Bowen v. Eli Lilly & Co., 
408 Mass. 204, 208 (1990). 
 
Although I agree with the court's articulation of our rule 
that, in the absence of explicit legislative direction, it may 
determine, as a matter of common law, when a cause of action 
accrues, and hence when the limitation period begins to run, see 
Franklin, 381 Mass. at 617, the absence of explicit statutory 
language does not mean that the court should act to change 
settled law in a manner inconsistent with legislative 
objectives.  See Rosenbloom v. Kokofsky, 373 Mass. 778, 780 
(1977).  In this case, the adoption of the continuing treatment 
doctrine runs contrary to the legislative aims undergirding the 
Commonwealth's medical malpractice statutory framework and 
ignores decades of work and study by the executive and 
legislative branches regarding reducing the cost of health care 
in the Commonwealth, ensuring both affordability and access.1  
                                                          
 
 
1 The Legislature has committed extensive resources to 
understanding and addressing the issue of rising health care 
costs, not only in the area of medical malpractice, but across 
the health care industry as a whole.  See House Committee Report 
concerning 2012 Senate Bill No. 2400, The Next Phase of 
Massachusetts Health Care Reform (between 2009 and 2020, "health 
spending is projected to double, outpacing both inflation and 
growth in the overall economy.  The rapid rate of growth 
squeezes out other spending, for individual households, for 
businesses, for communities and in the state budget.  That is 
why this effort [to address rising health care costs while 
improving health care quality and patient care] is essential for 
our long-term economic competitiveness and for the health of our 
residents").  To that end, it has mandated that various 
3 
 
 
Indeed, the court's ignorance of the impact on the cost of 
health care of its sudden change of mind on the accrual of 
malpractice claims is staggering.2  If ever there was a case that 
                                                                                                                                                                                           
executive agencies, including the Health Policy Commission, the 
office of the Attorney General, and the Department of Public 
Health, monitor and report on the costs of health care in the 
Commonwealth.  See G. L. c. 6D, § 8, as amended by St. 2013, 
c. 35, § 3 (mandating annual hearings and report concerning 
health care expenditures); G. L. c. 12, § 11N (mandating that 
Attorney General "monitor trends in the health care market" and 
granting authority to investigate medical providers and payers); 
G. L. c. 12C, § 17 (Attorney General tasked with investigating 
information "related to health care costs and cost trends, 
factors that contribute to cost growth within the commonwealth's 
health care system and the relationship between provider costs 
and payer premium rates"); St. 2012, c. 224, § 272 (mandating 
that Department of Public Health "create an independent task 
force . . . to study and reduce the practice of defensive 
medicine and medical overutilization in the commonwealth . . . .  
The task force shall file a report of its study, including its 
recommendations and draft of any legislation, if necessary 
. . ."). 
 
 
These agencies produce extensive annual reports on the 
issue of rising health care costs, as well as recommendations 
across a wide range of health care policy issues.  See, e.g., 
Health Policy Commission, 2015 Cost Trends Report, 
http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-
agencies/health-policy-commission/publications/2015-cost-trends-
report.pdf [https://perma.cc/C7ME-KMGN]; Office of the Attorney 
General, Examination of Health Care Cost Trends and Cost 
Drivers, (Sept. 18, 2015), http://www.mass.gov/anf/budget-taxes-
and-procurement/oversight-agencies/health-policy-
commission/annual-cost-trends-hearing/2015/cost-containment-5-
report.pdf [https://perma.cc/XK7N-S74D]; Center for Health 
Information and Analysis, Performance of the Massachusetts 
Health Care System, Annual Report, (Sept. 2015), 
http://www.chiamass.gov/assets/2015-annual-report/2015-Annual-
Report.pdf [https://perma.cc/5DZ6-VW2V]. 
 
 
2 The court writes that there is no reason to believe, let 
alone adequate factual information in the record, to support a 
belief that adoption of the continuing treatment doctrine will 
4 
 
 
cried out for judicial restraint and deferral to the branches of 
government best equipped to strike the proper balance between 
ensuring affordable and available health care with the 
protection of injured patients, this is it. 
 
1.  Legislative intent.  After our adoption of the 
discovery rule in Franklin, the Legislature amended G. L. 
c. 231, § 60D, regarding the limitations period during which a 
minor might bring a claim for medical malpractice.  See St. 1986 
c. 351, § 23.  The legislative history is clear that the 
Legislature knew that we had adopted the discovery rule, and 
this knowledge informed the course of the statute's amendment.  
See Annual Report of the Special Commission Relative to Medical 
Professional Liability Insurance and the Nature and Consequences 
of Medical Malpractice, 1987 House Doc. No. 5262.3  In addition, 
                                                                                                                                                                                           
affect enough claims to have any meaningful impact on the cost 
of medical malpractice insurance.  See ante at note 16.  This 
argument underscores the obvious:  the court simply cannot know, 
in the way the Legislature can, whether or how adoption of the 
doctrine will affect the cost of medical malpractice insurance.  
However, where concern over such costs has been a major driver 
behind legislative reform in this area, see discussion infra, it 
seems apparent to me that the court should take a more cautious 
approach to redefining this area of settled law. 
 
 
3 The Special Commission Relative to Medical Professional 
Liability Insurance and the Nature and Consequences of Medical 
Malpractice (commission) was established by St. 1975, c. 362, 
§ 12.  Its purposes included making recommendations to 
ameliorate the high cost of medical malpractice insurance.  The 
report, which issued in 1987, discussed the issues that led to 
the current version of G. L. c. 231, § 60D, including the 
enactment of the current limitations period: 
5 
 
 
our prior cases have carefully considered the intent of the 
Legislature in enacting major pieces of medical malpractice 
legislation, St. 1975, c. 362, and St. 1986 c. 351, and we have 
repeatedly acknowledged its concern regarding the costs 
associated with medical malpractice litigation and its efforts 
to ameliorate the costs of medical malpractice insurance.  See, 
e.g., Darviris v. Petros, 442 Mass. 274, 283-284 (2004) 
(describing medical malpractice act of 1986 as "an exhaustive 
statutory scheme governing medical malpractice claims" and 
concluding that "[e]xpanding the scope of damages available to 
plaintiffs who are victims of medical malpractice, and the 
period within which to make such claims, is contrary to the 
express intent of the Legislature in enacting St. 1986, 
                                                                                                                                                                                           
 
"Most actuarial experts that testified before both the 
Special Commission and the Committee on Insurance 
stated meaningful savings would be realized by a 
change to the statute of limitations.  At present, an 
action may be commenced within three years of 
discovery that there are grounds to initiate a suit 
for medical malpractice, but there is no limit on the 
time period in which such discovery must be made.  
Under Chapter 351, the statute of limitations for 
medical malpractice actions would be revised to place 
an outside limit on the time which a lawsuit may be 
commenced, that limit being seven years after the date 
of the occurrence which gave rise to the claim, except 
when the action is based upon the leaving of a foreign 
object in the body in which case no outside limit 
shall apply (Section 30, Chapter 351)."  (Emphasis 
added.) 
 
Annual Report of the commission, 1987 House Doc. 5262, at 9. 
6 
 
 
c. 351"); McGuiggan v. New England Tel. & Tel. Co., 398 Mass. 
152, 163 (1986) (Lynch, J., concurring) ("[T]he General Court 
has recently limited the amount that may be recovered by victims 
of medical malpractice in an attempt to solve what it perceives 
as a crisis in the medical profession brought about by the 
burgeoning cost of malpractice insurance.  St. 1986, c. 351.  
The Legislature has acted to restrict recovery by injured 
litigants in order to limit the expense of practicing 
medicine").  See also Paro v. Longwood Hosp., 373 Mass. 645, 647 
(1977) (tribunal requirement of medical malpractice act of 1975 
was enacted "as part of a comprehensive package designed to 
ensure the continued availability of medical malpractice 
insurance at a reasonable cost)". 
 
In sum, the result reached by the court today is anomalous 
in light of the legislative history and intervening decisions of 
this court, which recognize that the medical malpractice 
statutory framework is intended to moderate the cost and expense 
of medical malpractice litigation and that such a purpose is 
accomplished, in part, by the statute of limitations period.  
The court notes that the absence of legislative action cannot be 
interpreted as an affirmative rejection of the continuing 
treatment doctrine.  In reaching this conclusion, however, the 
court ignores the fact that the statutory scheme was developed 
in tandem with the common law, and that expanding the period in 
7 
 
 
which a medical malpractice claim may be brought markedly 
departs from the clear policy aims the Legislature sought to 
accomplish by repeatedly enacting legislation addressing 
malpractice claims, insurance, and the objective of reducing the 
time of exposure to such malpractice claims.  See note 2, supra. 
 
Finally, it is notable that the Legislature did include 
express "exceptions" to the limitations period in G. L. c. 231, 
§ 60D.  First, there is an exception so any child under the age 
of six "shall have until his ninth birthday" to bring a claim. 
Second, the seven-year statute of repose has an exception for 
"the leaving of a foreign object in the body."  Id.  Given the 
Legislature's consideration and inclusion of these exceptions, I 
cannot conclude that a "continuing treatment" exception should 
be inferred where it was not included by the Legislature.  "The 
fact that the Legislature specified one exception . . . 
strengthens the inference that no other exception was intended."  
Joslyn v. Chang, 445 Mass. 344, 350 (2005), quoting LaBranche v. 
A.J. Lane & Co., 404 Mass. 725, 729 (1989). 
 
Thus, contrary to the court's conclusion, it is apparent 
that, in the medical malpractice context, the Legislature has 
concurred with, and maintained, our uniformly applied "accrual" 
standard, as articulated in Franklin.4  The statutory history and 
                                                          
 
 
4 To the extent that the court relies on decisions from 
other jurisdictions in adopting the continuing treatment 
8 
 
 
framework reflect a legislative choice to balance the goals of 
protecting defendant health care providers from extended tort 
exposure from stale claims, and of eliminating the "manifest 
injustice" which would result without the discovery rule for 
plaintiffs who are "blameless[ly] ignoran[t]" of information 
which might have put them on inquiry notice for purposes of 
investigating and possibly pursuing a claim.  See Franklin, 381 
Mass. at 618. 
 
The decision today elevates this latter policy concern over 
the former, based on the court's belief that the continuing 
treatment exception to the discovery rule would benefit patients 
by addressing a shortcoming it perceives in our current law, 
namely that patients are unable to make informed judgments as to 
negligent treatment while such treatment is ongoing.  See, e.g., 
Harrison v. Valentini, 184 S.W.3d 521, 524 (Ky. 2005).  In 
adopting the continuing treatment exception, however, the court 
fails to consider future impacts to the health care industry -- 
impacts to which the Legislature has dedicated decades of study 
and, in response, carefully crafted legislation that reflects an 
effort to best balance competing policy concerns.  Where the 
Legislature's policy determinations are fairly clear, the court 
should defer to those judgments. 
                                                                                                                                                                                           
doctrine, those cases do not affect my view of what the 
Legislature intended. 
9 
 
 
 
2.  Adopting the exception by analogy.  I also disagree 
with the court's reasoning that our adoption of the continuing 
representation doctrine to the discovery rule in legal 
malpractice claims, see Murphy v. Smith, 411 Mass. 133, 137-138 
(1991), justifies the adoption of a continuing treatment 
exception to the discovery rule in medical malpractice claims.  
I disagree with the proposition that, "just as a wronged client 
is permitted to benefit from his or her attorney's efforts to 
correct a problem without the disruption of exploring the 
viability of a legal malpractice action, so, too, is a patient 
permitted that same benefit without the disruption of exploring 
the viability of a medical malpractice action."  Ante at     .  
This statement both mischaracterizes the rationale underlying 
the continuing representation doctrine, and downplays the 
significant differences and interests at stake in those two 
arenas. 
 
First, with respect to legal malpractice, as we have held, 
the continuing misrepresentation doctrine "recognizes that a 
person seeking professional assistance has a right to repose 
confidence in the professional's ability and good faith, and 
realistically cannot be expected to question and assess the 
techniques employed or the manner in which the services are 
rendered" (citation omitted).  Murphy, 411 Mass. at 137.  
Implicit in the doctrine is an understanding that a person 
10 
 
 
seeking legal services may not recognize that certain acts or 
omissions by an attorney constitute malpractice.  Our 
justification of the doctrine says nothing, however, about 
permitting the representation to continue so that an attorney 
may correct an error arising from the attorney's conduct; to the 
contrary, the facts in Murphy suggest that the attorney accused 
of malpractice did nothing to correct his alleged error.  Id. 
 
Moreover, the rationale for adopting the continuing 
representation doctrine is largely distinguishable from any 
analogous rule in the medical malpractice context.  The 
"continuing representation" principle that we recognized in the 
context of legal malpractice arose from assurances given by an 
attorney that he had attended to a legal issue that had no 
perceptible manifestation to the client.  See id. at 136.  In 
the field of legal malpractice, there are situations, such as 
the one presented by Murphy, where the attorney may assure the 
client that a certain task has been carried out correctly and 
where the client should be able to accept such representations 
in the absence of information to the contrary.  Such a rule 
makes sense in the legal malpractice context because the alleged 
act or omission which gives rise to a claim and causes an injury 
to the plaintiff is caused somewhere other than in the 
plaintiff's own body, often under circumstances remote from a 
plaintiff's ability to detect circumstances which might put him 
11 
 
 
or her on notice of a claim.  See, e.g., Murphy, 411 Mass. at 
137 (plaintiffs unaware of attorney's purportedly improper 
certification of good record title until receipt of letter from 
neighbor's attorney).  The same cannot be said about the injury 
in a medical malpractice case, especially where the defendant's 
actions had a direct and perceptible effect on the patient's 
body. 
 
The court also justifies its adoption of the continuing 
treatment exception by analogy to the continuing representation 
doctrine in legal malpractice on the ground that the Legislature 
otherwise used almost identical language to describe the 
limitations period for medical malpractice claims and for legal 
malpractice claims.  It is apparent, however, that the 
Commonwealth's legislation governing medical malpractice was 
enacted in light of a number of competing policy concerns that 
are unique to the health care industry -- concerns simply not 
present in the practice of law -- a practice that we as a court 
regulate.5 
                                                          
 
 
5 The language in context is different.  As discussed, there 
is a statute of limitations that the Legislature enacted 
specifically to address medical malpractice and an even more 
specialized statute for cases involving minors.  See G. L. 
c. 231, § 60D; G. L. c. 260, § 4.  The medical malpractice 
limitations statute includes a statute of repose, but the 
statute for legal malpractice does not.  The medical malpractice 
statute applicable to juveniles eliminates tolling until the 
minor's eighteenth birthday (G. L. c. 260, § 7), but the legal 
malpractice statute does not.  Compare G. L. c. 260, § 4, first 
12 
 
 
 
3.  Conclusion.  The court's adoption of the continuing 
treatment exception to the discovery rule is inconsistent with 
the apparent legislative objectives underlying the 
Commonwealth's medical malpractice statutory regime, 
particularly G. L. c. 231, § 60D.  In my view, the court should 
apply the settled discovery rule to the facts of this case.  As 
the court acknowledges, the defendant's treatment ceased in 
December, 2005.  Therefore, the plaintiffs' action, brought in 
2009, was not timely. 
 
                                                                                                                                                                                           
par., with G. L. c. 231, § 60D.  This express statutory language 
unmistakably demonstrates that the Legislature intentionally 
differentiated the medical malpractice and legal malpractice 
statutes of limitation.