Case Title: St. George v. Pariser

Citation: 

Docket Number: 960876

State: virginia

Court: Virginia Supreme Court

Date: 1997-04-18T00:00:00Z

Document:
Present:  All the Justices  
 
LINDA M. ST. GEORGE 
 
v.   Record No. 960876 
OPINION BY JUSTICE ELIZABETH B. LACY 
                                          April 18, 1997 
ROBERT J. PARISER, M.D., ET AL. 
 
 
FROM THE CIRCUIT COURT OF THE CITY OF NORFOLK 
 
Marc Jacobson, Judge 
 
 
The primary issue in this medical malpractice case is 
whether the defendants, who filed a plea of the statute of 
limitations, carried their burden of producing evidence to show 
that the patient's injury occurred more than two years before 
the date the motion for judgment was filed. 
 
This case involves the misdiagnosis of a cancerous mole.  
On June 13, 1991, Linda M. St. George went to the offices of 
Pariser Dermatology Specialists, Ltd., for an evaluation of a 
mole on her lower left leg.  A punch biopsy was performed on 
the mole.  Robert J. Pariser, M.D., an owner and employee of 
Pariser Dermatology Specialists, Ltd., performed a pathological 
examination of the biopsied tissue.  He diagnosed the tissue as 
acanthoma, a benign condition.  This diagnosis was placed in 
St. George's medical record and relayed to her. 
 
In March 1993, St. George consulted a plastic surgeon, Dr. 
Tad E. Grenga, about removal of the mole.  At Dr. Grenga's 
suggestion, St. George requested a copy of her medical record 
from Pariser Dermatology Specialists, Ltd.  Prior to delivering 
the record, Dr. Pariser reviewed the 1991 tissue slides and 
determined that the biopsied tissue showed atypical melanocytic 
hyperplasia, a cancerous condition.  He put an addendum report 
 
 
 
 
2 
                    
in St. George's medical record reflecting this second 
diagnosis.   
 
After reviewing the medical record, including Dr. 
Pariser's addendum report, Dr. Grenga determined that the 
condition described in the addendum report required that the 
entire mole be removed, which he did by an excisional biopsy.  
The pathology report described the biopsied tissue as "invasive 
superficial spreading malignant melanoma."  Based on this 
report, Dr. Grenga performed a second surgery in which he 
removed additional tissue around the site of the mole and 
closed the wound with a skin graft.  St. George underwent 
subsequent procedures including implantation of a tissue 
expander.  The tissue expander was ultimately removed at St. 
George's request because of the pain and nerve numbness 
associated with it.  St. George continues to have periodic 
examinations and tests by an oncologist to insure that the 
cancer has not recurred. 
 
On October 21, 1993, St. George filed a motion for 
judgment against Dr. Pariser and Tidewater Dermapathology 
Service, Inc., alleging negligence and fraud.  Pariser 
Dermatology Specialists, Ltd., was later added as a defendant.
1 
 Dr. Pariser and Pariser Dermatology Specialists, Ltd., 
(collectively "Pariser") filed a demurrer to the fraud count 
 
     
1Tidewater Dermapathology Service, Inc., and Dr. David M. 
Pariser, another defendant, were nonsuited prior to trial. 
 
 
 
 
3 
which was sustained.  Pariser also filed a plea of the statute 
of limitations, asserting that St. George's cause of action 
arose at the time of the June 1991 diagnosis and, therefore, 
her motion for judgment was filed beyond the two year statute 
of limitations period.  Code § 8.01-243(A).  St. George sought 
a determination by the trial court that her motion for judgment 
was timely filed as a matter of law.  The trial court took this 
matter under advisement.  Following the presentation of the 
evidence in a three day trial, the trial court granted St. 
George's motion to strike Pariser's evidence on the issue of 
negligence.  The case was submitted to the jury on the issues 
of proximate cause, damages, and the statute of limitations.  
The jury returned a verdict in favor of Pariser.  St. George 
filed this appeal asserting that the trial court erred in 
failing to strike Pariser's plea of the statute of limitations 
as a matter of law.   
 
The law governing the accrual of a cause of action 
involving a claim for personal injury is well established.  The 
cause of action accrues on "the date the injury is sustained in 
the case of injury to the person," § 8.01-230, and we have 
construed "injury" to mean "a positive, physical or mental 
hurt."  Locke v. Johns-Manville Corp., 221 Va. 951, 957, 275 
S.E.2d 900, 904 (1981).  The injury need not occur 
contemporaneously with the negligent act, but may arise at some 
later point.  Id. at 957-59, 275 S.E.2d at 904-05.  Finally, an 
 
 
 
 
4 
injury is deemed to occur, and the statute of limitations 
period begins to run, whenever any injury, however slight, is 
caused by the negligent act, even though additional or more 
severe injury or damage may be subsequently sustained as a 
result of the negligent act.  Scarpa v. Melzig, 237 Va. 509, 
512, 379 S.E.2d 307, 309 (1989).  The party asserting the 
limitations bar bears the burden of proving the date on which 
the injury was sustained with a reasonable degree of medical 
certainty.  Lo v. Burke, 249 Va. 311, 316, 455 S.E.2d 9, 12 
(1995).  
 
We turn then to the record to determine whether Pariser 
produced evidence to show when, based on the expert testimony, 
the injury St. George suffered as a result of the misdiagnosis 
occurred, and whether that date was more than two years prior 
to the date she filed her motion for judgment.  There was 
virtually no disagreement among the physicians who qualified as 
expert witnesses at trial about the pathology of St. George's 
mole.  The experts agreed that the 1991 biopsy slides show 
atypical melanocyte cells in the epidermis.  These cells, 
according to the experts, are cancerous and can be called a 
melanoma or a malignant melanoma.
2  The experts also testified 
that these cells are capable of multiplying, but as long as the 
                     
     
2St. George's expert, Dr. Philip H. Cooper, declined to 
describe the condition as cancerous, defining "cancer" as 
including a condition which has the ability to "locally invade 
tissue beyond where it starts" and "the potential to 
metastasize."   
 
 
 
 
5 
growth is confined to the epidermis, they cannot metastasize or 
move into other areas of the body.  Pariser's experts referred 
to St. George's condition in 1991 as "melanoma in situ."  The 
experts also agreed that complete removal of these cells or 
melanoma at this point would have eliminated any possibility of 
a recurrence of the cancerous condition because of this 
melanoma, either at the removal site or at any other part of 
the body.  Dr. Albert Ackerman, one of Pariser's experts, 
described the "melanoma in situ" as "biologically benign." 
 
The experts further agreed that the 1993 biopsy showed 
that St. George's condition had altered from its 1991 status. 
Specifically, the melanoma had enlarged and moved into the 
dermis.  The experts explained that once the melanoma invaded 
the dermis, it was capable of metastasizing.  In this status, 
according to the experts, even complete removal of the melanoma 
from the dermis at this point could not insure that the 
cancerous condition would not recur in another part of the body 
as a result of the movement of some of the cells from the 
melanoma.  The experts all stated that St. George has some 
likelihood of recurrence of the cancer from the melanoma, even 
though they differed as to the exact percentage.  Furthermore, 
both Dr. Ackerman and Dr. Cooper testified that if cancer were 
to recur from this melanoma, the chances that the recurrent 
cancer would be fatal would increase. 
 
Pariser contends that, although the expert testimony did 
 
 
 
 
6 
not establish the date of the onset of cancer in St. George, it 
did establish with reasonable medical certainty that St. George 
had a cancerous condition in 1991 when she presented herself 
for the initial diagnosis.  Thus, because St. George's motion 
for judgment was not filed within two years after her initial 
diagnosis, the trial court was correct in denying St. George's 
motion to strike Pariser's plea of the statute of limitations. 
 St. George replies that her injury was not the onset of 
cancer.  She claims her injury occurred when the cancer or 
melanoma moved from the epidermis into the dermis.  She 
contends she was injured at that point as a result of the 
misdiagnosis because, deprived of the opportunity to have the 
mole removed in 1991 when the cancer was confined to the 
epidermis, she became subject to the risk of recurrence of the 
cancer from the melanoma, and treatment for the melanoma 
required more extensive surgery and periodic testing.  We agree 
with St. George. 
 
Before addressing when an injury arises for statute of 
limitations purposes, we must first identify the actionable 
injury.  This is a misdiagnosis case, not a malpractice action 
based on negligently performed surgery.  Compare Scarpa v. 
Melzig, 237 Va. 509, 379 S.E.2d 307 (1989).  In every 
misdiagnosis case, the patient has some type of medical problem 
at the time the physician is consulted.  But the injury upon 
which the cause of action is based is not the original 
 
 
 
 
7 
detrimental condition; it is the injury which later occurs 
because of the misdiagnosis and failure to treat.  For example, 
in Lo v. Burke, the actionable injury was not the cyst the 
plaintiff had when she went to the doctor, although this was a 
medical problem which should have been treated.  The injury at 
issue was the cancer which developed from the cyst.  249 Va. at 
315-17, 455 S.E.2d at 12-13.  Similarly, in Jenkins v. Payne, 
251 Va. 122, 465 S.E.2d 795 (1996), the injury was the wrongful 
death of a patient who presented to the physician with a 
cancerous condition which was not diagnosed or treated before 
the condition became terminal.  See also Renner v. Stafford, 
245 Va. 351, 429 S.E.2d 218 (1993)(actionable injury was 
condition caused by improper treatment rendered because of 
misdiagnosis).  "Where a medical malpractice claim is based on 
a misdiagnosis or failure to diagnose a condition, the 'injury' 
. . . is the development of the problem into a more serious 
condition which poses greater danger to the patient or which 
requires more extensive treatment."  DeBoer v. Brown, 673 P.2d 
912, 914 (Ariz. 1983).   
 
 In this case, St. George's actionable injury was not the 
generic disease of cancer or the cancer "in situ" which she had 
when she sought evaluation of the mole in 1991.  Pariser's 
negligence could not have been the cause of that medical 
condition.  St. George's injury was the change in her cancerous 
condition which occurred when the melanoma altered its status 
 
 
 
 
8 
as "melanoma in situ," a biologically benign condition, to 
"invasive superficial spreading malignant melanoma" in the 
dermis which allowed the melanoma cells to metastasize to other 
parts of the body.  At this point, St. George's cancer, 
according to the expert testimony, was no longer 100 percent 
curable because the cancer could metastasize and recur.  
Additionally, the treatment then required to remove the 
melanoma was more extensive and included post-surgical 
monitoring to insure that the cancer had not recurred. 
 
 To carry his burden on the limitations plea, therefore, 
Pariser was required to show, with reasonable medical 
certainty, that this injury, the movement of the cancer from 
the epidermis to the dermis, occurred prior to October 21, 
1991.  The only evidence in the record on the issue of when the 
injurious change occurred is Dr. Cooper's testimony that he 
believed the change happened after January 1992.  There is 
nothing in the record which would place the date of the injury 
more than two years prior to the filing of the motion for 
judgment in this case.  Thus, Pariser wholly failed to meet his 
burden of proof to sustain his statute of limitations plea, and 
the trial court erred in denying St. George's motion to strike 
the plea as a matter of law. 
 
St. George also asserts that she adequately pled a cause 
of action for constructive fraud, and the trial court erred in 
sustaining Pariser's demurrer to her fraud count.  This 
 
 
 
 
9 
assignment of error is without merit.  The facts alleged in St. 
George's pleadings describe only the negligent performance of 
the initial biopsy, not negligent misrepresentation. 
 
Accordingly, for the reasons stated, we will reverse the 
judgment of the trial court in part, and remand the case for 
entry of an order denying Pariser's plea of the statute of 
limitations as a matter of law and for further proceedings on 
the issues of proximate cause and damages based on St. George's 
negligence count. 
 
Affirmed in part,
                                              reversed in part,
                                              and remanded.