Case Title: Hinkley v. Koehler

Citation: 

Docket Number: 040389

State: virginia

Court: Virginia Supreme Court

Date: 2005-01-14T00:00:00Z

Document:
Present:  All the Justices 
 
ELIZABETH K. HINKLEY 
 
v.  Record No. 040389  OPINION BY JUSTICE CYNTHIA D. KINSER 
 
 
 
 
 
 
 
 
January 14, 2005 
ANTHONY J. KOEHLER, M.D., ET AL. 
 
FROM THE CIRCUIT COURT OF MONTGOMERY COUNTY 
Robert M. D. Turk, Judge 
 
 
Elizabeth K. Hinkley filed this medical malpractice 
action, naming as defendants Anthony J. Koehler, M.D.; 
Sanam Emami Campbell, M.D.; David J. Roberts, M.D. 
(collectively, “the defendant doctors”); and their employer 
Southwest Virginia Physicians for Women, Inc., d/b/a 
Obstetrics & Gynecology of Radford (collectively, “the 
defendants”).1  A jury returned a verdict for the 
defendants. 
We awarded Hinkley this appeal on the question whether 
the circuit court erred in concluding that one of the 
defendants’ witnesses was qualified under Code § 8.01-
581.20(A) to give expert testimony with regard to the 
standard of care.  Because the expert witness had not had 
an active clinical practice in the defendant doctors’ 
specialty or a related field within one year of the alleged 
                                                 
1 Hinkley also named as defendants Carilion New River 
Valley Medical Center along with several of its employees.  
Before trial, Hinkley took a nonsuit as to these 
defendants. 
 
2
negligence, we will reverse the judgment of the circuit 
court. 
During her 28th week of a twin pregnancy, Hinkley 
sought medical attention due to decreased fetal movements 
and contractions.  Over the course of two days, August 23 
and 24, 2001, the defendant doctors attended to Hinkley and 
her twin fetuses, primarily by monitoring the twin fetuses’ 
heart rates, conducting ultrasound examinations, and 
reducing Hinkley’s contractions.  On the second day, an 
ultrasound examination revealed that one of the twins had 
died in utero.  The ultrasound test, along with a Doppler 
study, indicated that the other twin had “no major 
anomalies.”  However, later that day, the other twin died 
in utero, as confirmed by a second ultrasound examination.  
Hinkley then underwent a cesarean section to deliver the 
dead fetuses.  The preliminary post-operative diagnosis 
regarding the cause of death was twin-to-twin transfusion 
syndrome.2 
 
Prior to trial, Hinkley filed a motion in limine to 
exclude testimony from Charles Greenhouse, M.D., one of the 
expert witnesses designated by the defendant doctors to 
testify with regard to the standard of care.  Hinkley 
                                                 
2 No autopsies were performed on the twin fetuses; 
therefore, the cause of death was disputed at trial. 
 
 
3
argued that Dr. Greenhouse did not meet the requirements of 
Code § 8.01-581.20(A) because he had not practiced in the 
field of obstetrics within one year of the date of the 
alleged negligence and had not delivered a baby since 1998.  
The circuit court took the motion under advisement until 
Dr. Greenhouse testified at trial. 
 
During the trial, the circuit court heard testimony, 
outside the presence of the jury, from Dr. Greenhouse about 
his qualifications.  Dr. Greenhouse testified that he had 
practiced medicine in the field of obstetrics and 
gynecology for 33 years but that he “gave up delivering, 
hands-on delivering obstetrics [in] November of 1998.”  
Since 1998, Dr. Greenhouse had “been extremely active in 
teaching . . . residents . . . , medical students and 
interns [in] obstetrics and gynecology" as an associate 
clinical professor at George Washington University Medical 
School, and in performing consultative work with those 
individuals, as well as with the partners in his six-person 
medical practice.  Dr. Greenhouse consulted primarily with 
regard to high-risk pregnancy cases and associated 
problems.  Although Dr. Greenhouse testified that he had 
consulted on two patients “which [he] actually went in and 
spoke to,” he acknowledged that he was not the “primary 
care physician for those patients” and had not been for any 
 
4
obstetrical patient since November 1998.  Dr. Greenhouse 
explained that a primary care physician means “the doctor 
who is responsible for that patient.”  In Dr. Greenhouse’s 
words, “I don’t deliver the patient; however, I am very 
active in the consulting part.”  Finally, Dr. Greenhouse 
testified that he recently had been asked to be on the 
editorial board review of a journal for obstetrics and 
gynecology and to do “peer review work for the Medical 
Gynecological Society in obstetrical cases.” 
 
Based on this testimony, the circuit court concluded, 
over Hinkley’s objection, that Dr. Greenhouse was qualified 
and accordingly admitted him as an expert in the field of 
obstetrics on both the standard of care and causation.  The 
court reasoned that Dr. Greenhouse’s consultative work on a 
regular basis with physicians who practice obstetrics on a 
daily basis qualified Dr. Greenhouse under the requirements 
of Code § 8.01-581.20(A).  The court also viewed the 
provisions of that statute as requiring that “one with 
certain qualifications shall be considered an expert [but 
that the statute] doesn’t say that these are the only 
qualifications that [a physician has] to have in order to 
testify as an expert.”  According to the court, “the 
statute doesn’t say these are the only individuals” who 
qualify. 
 
5
 
When the jury returned to the courtroom, Dr. 
Greenhouse testified similarly with regard to his 33 years 
of practice in the field of obstetrics and gynecology, and 
his teaching and consulting work in the field of 
obstetrics.  He further stated that he has a full 
gynecology practice, seeing “patients from all categories 
gynecologically.”  He again admitted that he had not been 
the primary care physician for any pregnant mother or 
delivered a baby since November 1998. 
 
In order to qualify as an expert on the standard of 
care in a medical malpractice action, a witness must 
satisfy the statutory criteria set forth in Code § 8.01-
581.20(A).  Perdieu v. Blackstone Family Practice Ctr., 
Inc., 264 Va. 408, 419, 568 S.E.2d 703, 709 (2002); see 
also Sami v. Varn, 260 Va. 280, 283, 535 S.E.2d 172, 174 
(2000) (“[t]he qualification of a witness as an expert is 
governed by Code § 8.01-581.20”).  In relevant part, that 
statute states: 
A witness shall be qualified to testify as an 
expert on the standard of care if he demonstrates 
expert knowledge of the standards of the 
defendant’s specialty and of what conduct conforms 
or fails to conform to those standards and if he 
has had active clinical practice in either the 
defendant’s specialty or a related field of 
medicine within one year of the date of the alleged 
act or omission forming the basis of the action. 
 
 
6
Code § 8.01-581.20(A).  We previously characterized these 
requisites as the “knowledge requirement” and the “active 
clinical practice requirement.”  Wright v. Kaye, 267 Va. 
510, 518, 593 S.E.2d 307, 311 (2004).  Contrary to the 
circuit court’s comments when ruling on the motion in 
limine, both of the requirements must be satisfied before 
an expert can testify as to the standard of care.  Id. 
In this case, the active clinical practice requirement 
is at issue, i.e., whether Dr. Greenhouse’s teaching and 
consulting work within one year of the date of the alleged 
negligence forming the basis of the action constituted an 
“active clinical practice” within the intendment of Code 
§ 8.01-581.20(A).  “[W]hether a proffered witness meets the 
active clinical practice requirement is . . . determined by 
reference to the relevant medical procedure.”  Id. at 522, 
593 S.E.2d at 313.  For example, in Wright, the relevant 
procedure was “laparoscopic surgery in the female pelvic 
area near the bladder involving a surgical stapler.”  Id.  
We found that the plaintiff’s experts in that case had an 
active clinical practice with regard to the procedure at 
issue within the one-year statutory window.  Id.  However, 
the crux of that case, with regard to the active clinical 
practice requirement, focused on and rejected the defendant 
doctor’s argument that an active clinical practice in the 
 
7
defendant’s specialty meant that “an expert witness must 
have performed the same medical procedure with the same 
pathology in all respects as gave rise to the alleged act 
of malpractice at issue in order to have practiced in the 
defendant’s specialty.”  Id. at 523, 593 S.E.2d at 314. 
In contrast, the expert witness in Fairfax Hosp. Sys., 
Inc. v. Curtis, 249 Va. 531, 457 S.E.2d 66 (1995), did not 
qualify under the provisions of Code § 8.01-581.20(A) even 
though up until approximately two years prior to the 
alleged negligence forming the basis of that action he had 
worked as a professor of pediatrics and as medical director 
of a hospital’s pediatric intensive care unit.  Id. at 536-
37, 457 S.E.2d at 70.  The expert’s work at the time of the 
alleged negligence, as the director of a service that 
transported sick and injured patients by helicopter, could 
not be deemed an active clinical practice.  Id. at 537, 457 
S.E.2d at 70. 
Likewise in Perdieu, we held that two expert witnesses 
did not have an active clinical practice during the 
relevant statutory time period.  264 Va. at 419-20, 568 
S.E.2d at 709-10.  The alleged negligence forming the basis 
of that action concerned the care of nursing home patients, 
including the diagnosis of fractures.  Id. at 420, 568 
S.E.2d at 710.  One of the experts had previously worked as 
 
8
the head of a hospital’s emergency medicine department and 
had operated a “walk-in clinic for primary care.”  Id. at 
413, 568 S.E.2d at 706.  However, during the relevant time 
period, the expert had worked one day per week in a clinic 
and one day per week at a county’s health department.  He 
had not treated fractures or cared for nursing home 
patients.  Id. at 420, 568 S.E.2d at 710.  The other 
expert’s prior experience had been in “the field of general 
practice,” which had included the treatment of nursing home 
patients and fractures.  Id. at 415, 568 S.E.2d at 707.  
However, since his retirement approximately eight years 
before the alleged negligence at issue in that case, the 
expert’s only work in the medical field had been as the 
“medical officer” for a senior citizen softball league.  
Id.  We concluded that neither expert had “ ‘recently 
engaged in the actual performance of the procedures at 
issue’ ” in that case.3  Id. at 420, 568 S.E.2d at 710 
(quoting Sami, 260 Va. at 285, 535 S.E.2d at 175). 
 
Although these cases are instructive, they do not 
provide a definitive answer in this case.  This is so 
because we have never, in those cases or otherwise, defined 
                                                 
3 We also found a third expert witness was not 
qualified because her only experience with nursing home 
patients was in an acute-care setting such as a hospital.  
Perdieu, 264 Va. at 419-20, 568 S.E.2d at 709-10. 
 
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the phrase “active clinical practice” nor have we addressed 
whether an expert who only taught and consulted in a 
defendant’s specialty or a related field of medicine during 
the statutory one-year window nevertheless had an “active 
clinical practice” within the contemplation of Code § 8.01-
581.20(A).  But, we have stated that we determine whether a 
proffered expert witness satisfies the active clinical 
practice requirement by referring to the “relevant medical 
procedure” at issue in a case.  Wright, 267 Va. at 522, 593 
S.E.2d at 313.  We also have explained that the phrase 
“ ‘actual performance of the procedures at issue’ must be 
read in the context of the actions by which the defendant 
is alleged to have deviated from the standard of care.”  
Id. at 523, 593 S.E.2d at 314.  The question whether a 
proffered expert witness met the active clinical practice 
requirement must be analyzed in the same manner.  Thus, in 
this case, we determine whether Dr. Greenhouse, as a 
teacher and consultant in the field of obstetrics, 
fulfilled the active clinical practice requirement by 
examining “the context of the actions by which the 
defendant[s] [are] alleged to have deviated from the 
standard of care.”  Id. 
 
The alleged negligence forming the basis of this 
action arose out of the direct patient care provided to 
 
10
Hinkley during her pregnancy; and the management, 
treatment, and delivery decisions that were made when she 
sought medical attention because of decreased fetal 
movements and contractions.  Hinkley alleged in the motion 
for judgment that the defendant doctors were negligent by 
failing to provide proper medical treatment, primarily 
testing; and by failing to intervene surgically to save the 
life of the remaining twin after one had died in utero.  
Her expert witnesses testified that the defendant doctors 
breached the standard of care by failing to perform certain 
tests to determine, not just whether the twins were alive, 
but also whether they were in distress.  They further 
opined that the standard of care required that a 
recommendation be made to the parents to proceed with 
delivery especially after one of the twins had died in 
utero. 
However, within the one-year statutory time period, 
Dr. Greenhouse did not directly care for, provide treatment 
or management to, or make delivery decisions for any 
pregnancy.  In other words, he had not, as a teacher and 
consultant in the field of obstetrics, provided direct 
patient care for any pregnancy since November 1998.  Yet, 
this type of direct patient care is “the context of the 
actions by which the defendant[s] [are] alleged to have 
 
11
deviated from the standard of care.”  Wright, 267 Va. at 
523, 593 S.E.2d at 314.  Thus, we conclude that Dr. 
Greenhouse did not satisfy the active clinical practice 
requirement. 
 
The defendants acknowledge on brief that “the only 
issue was whether the defendant physicians met the 
applicable standard of care in their evaluation, 
management, and treatment of . . . Hinkley’s evolving 
calamity.”  They argue that, since this case is not about a 
specific procedure that the defendant doctors physically 
performed or the technique of delivering babies, Dr. 
Greenhouse was qualified under Code § 8.01-581.20(A) 
because he was actively engaged in the management of 
problems associated with pregnancies.  The defendants argue 
that the only thing Dr. Greenhouse no longer did was 
personally to deliver babies.  We agree that neither a 
specific procedure nor the physical process of delivering a 
baby is at issue here, but Dr. Greenhouse did not evaluate, 
manage, or treat problems in pregnancies in the context of 
direct patient care as did the defendant doctors.  Nor are 
we persuaded otherwise by Dr. Greenhouse’s testimony that 
he actually talked to two patients for whom he was acting 
as a consultant.  Moreover, his testimony in that regard 
 
12
did not indicate whether that particular consultation 
occurred within the statutory time period. 
 
As we have said on many occasions, ascertaining 
whether a proffered witness is qualified to testify as an 
expert is a determination lying within the sound discretion 
of the trial court.  Wright, 267 Va. at 520, 593 S.E.2d at 
312; Perdieu, 264 Va. at 418, 568 S.E.2d at 709; Noll v. 
Rahal, 219 Va. 795, 800, 250 S.E.2d 741, 744 (1979); 
Swersky v. Higgins, 194 Va. 983, 985, 76 S.E.2d 200, 202 
(1953).  “A trial court will not be reversed for allowing a 
witness to testify as an expert unless it appears clearly 
that he was not qualified in the field in which he gives 
evidence.”  Swersky, 194 Va. at 985, 76 S.E.2d at 202.  
There is not, as suggested by the defendants, a lower 
standard of appellate review when a trial court excludes 
the testimony of a proffered expert witness as compared to 
when the court admits the testimony.  “ ‘A trial court’s 
exercise of its discretion in determining whether to admit 
or exclude evidence will not be overturned on appeal absent 
evidence that the trial court abused that discretion.’ ”  
Wright, 267 Va. at 517, 593 S.E.2d at 310 (emphasis added) 
(quoting May v. Caruso, 264 Va. 358, 362, 568 S.E.2d 690, 
692 (2002)). 
 
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For the reasons stated, we conclude that the circuit 
court abused its discretion in this case by permitting Dr. 
Greenhouse to testify as to the standard of care.  In the 
context of the alleged negligence at issue, Dr. 
Greenhouse’s work as a teacher and consultant did not 
satisfy the active clinical practice requirement set forth 
in Code 8.01-581.20(A).4  One of the purposes of that 
requirement is to prevent testimony by individuals who do 
not provide healthcare services in the same context in 
which it is alleged that a defendant deviated from the 
standard of care.  Today’s decision is in accord with that 
purpose. 
Finally, we reject the defendants’ argument that any 
error by the circuit court in allowing Dr. Greenhouse to 
testify was harmless.  The defendants assert that Dr. 
Greenhouse testified about not only the standard of care 
but also causation, that Hinkley has not articulated any 
reason why Dr. Greenhouse was not qualified to testify as 
to the issue of causation, and that the “jury’s verdict was 
far more likely decided on the issue” of causation.  This 
last assertion is purely speculative; neither the 
                                                 
4 However, we find no merit in Hinkley’s argument that 
Dr. Greenhouse did not satisfy the requirements of Code 
§ 8.01-581.20(A) merely because he personally had never had 
an obstetrical patient with twin-to-twin transfusion 
syndrome. 
 
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defendants nor this Court can ascertain on what issue the 
jury returned its verdict in favor of the defendants.  See 
Schlimmer v. Poverty Hunt Club, 268 Va. 74, 80, 597 S.E.2d 
43, 46 (2004) (finding error was not harmless because we 
could not determine whether the jury returned a verdict for 
the defendant due to lack of primary negligence or due to 
plaintiff’s contributory negligence). 
Furthermore, the error in allowing Dr. Greenhouse to 
testify with regard to the standard of care “is presumed to 
be prejudicial unless it plainly appears that it could not 
have affected the result.”  Spence v. Miller, 197 Va. 477, 
482, 90 S.E.2d 131, 135 (1955); accord Clohessy v. Weiler, 
250 Va. 249, 254, 462 S.E.2d 94, 97 (1995).  In this case, 
it does not plainly appear from the record that the error 
could not have affected the jury’s verdict.  This is so 
despite the fact that the defendants had another expert 
witness, Wade A. Neiman, M.D., who testified as to both 
standard of care and proximate causation. 
 
However, Dr. Greenhouse’s testimony was in many 
respects more detailed than Dr. Neiman’s testimony.  The 
jury also could have accorded more weight to Dr. 
Greenhouse’s testimony overall because of his 33 years of 
experience in the practice of medicine.  See Black v. 
Bladergroen, 258 Va. 438, 446, 521 S.E.2d 168, 172 (1999) 
 
15
(considering qualifications of expert witness whose 
testimony was excluded in deciding issue of harmless 
error). 
 
For these reasons, we will reverse the judgment of the 
circuit court and remand this case for a new trial.5 
Reversed and remanded. 
                                                 
5 In light of our decision, we do not decide whether 
Dr. Greenhouse was qualified to testify solely on the issue 
of causation.  We simply point out that the requirements of 
Code § 8.01-581.20(A) speak only to qualifications needed 
for an expert to testify about the standard of care.