Case Title: Gamache v. Allen

Citation: 

Docket Number: 032321

State: virginia

Court: Virginia Supreme Court

Date: 2004-09-17T00:00:00Z

Document:
Present:  All the Justices 
 
DONNA J. GAMACHE, M.D., ET AL. 
 
 
      OPINION BY CHIEF JUSTICE LEROY R. HASSELL, SR. 
v.  Record No. 032321 
 September 17, 2004 
 
CRAIG ALLEN 
 
FROM THE CIRCUIT COURT OF THE CITY OF FREDERICKSBURG 
John W. Scott, Jr., Judge 
 
I. 
 
In this appeal of a judgment entered in favor of 
plaintiff in an action for medical negligence against two 
health care providers, we consider whether the circuit court 
erred by refusing to permit defendants to cross-examine 
plaintiff and his witnesses on certain issues that related to 
his claim for damages. 
II. 
A. 
 
Plaintiff, Craig Allen, filed his motion for judgment 
against Donna J. Gamache, M.D., her employer, Mid-Atlantic 
Health Alliance, Inc., t/a Lee's Hill Medical Associates, and 
another physician, Timothy A. Powell, M.D.  Plaintiff alleged 
that the defendants breached certain duties owed to him by 
failing to diagnose and treat a disease that affected his 
cervical spine. 
 
Prior to trial, plaintiff filed motions in limine.  
Plaintiff informed the circuit court that he intended to 
 
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present evidence that would permit the jury to conclude that 
he attempted to commit suicide in April 2002 and that this act 
was proximately caused by the negligence of the health care 
providers.  He also informed the court that the health care 
providers intended to present evidence that plaintiff's 
attempt to commit suicide was related to other factors, 
specifically, his wife's alleged abuse of narcotics and his 
wife's alleged acts of self-mutilation.  Defendants asserted 
in the circuit court that they were entitled to show the jury 
that these acts caused plaintiff to attempt to commit suicide.  
The court granted the motions in limine.  The court ruled that 
defendants could present evidence regarding depression that 
plaintiff's wife suffered, but they could not present evidence 
of her alleged abuse of narcotics or her alleged acts of self-
mutilation. 
B. 
 
During a jury trial, plaintiff presented the following 
evidence.  Plaintiff met with Dr. Gamache on June 22, 2000.  
He informed her that he had experienced mild anxiety and that 
he had used a drug, Ativan (a brand name for Lorazepam), that 
had been prescribed by his former physician.  Dr. Gamache 
prescribed a different anti-anxiety medication, BuSpar 
(buspirone hydrochloride), for plaintiff. 
 
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On July 25, 2000, plaintiff placed a telephone call to 
Dr. Gamache's office, and he complained of muscle aches, 
numbness, and "pins-and-needles" sensations in his arms and 
legs.  He did not speak with Dr. Gamache, but he spoke with a 
receptionist who informed plaintiff that he was possibly 
experiencing symptoms associated with the use of BuSpar and 
that he should decrease the daily dosage. 
 
Even though plaintiff decreased his dosage of BuSpar as 
instructed by Dr. Gamache's office, he experienced additional 
problems in his arms and legs.  On August 17, 2000, plaintiff 
made another telephone call to Dr. Gamache's office and 
described his symptoms.  Again, he spoke with the 
receptionist, not with Dr. Gamache.  The receptionist informed 
plaintiff that he was merely experiencing side effects of 
BuSpar that would last six to eight weeks from the date he 
discontinued use of that drug. 
 
Later, someone from Dr. Gamache's office contacted 
plaintiff and asked if he desired to come to the office for an 
appointment on September 1, 2000.  Plaintiff met with Dr. 
Gamache on September 1 and described his symptoms to her.  Dr. 
Gamache did not examine plaintiff and assured him that he was 
experiencing symptoms associated with the use of BuSpar.  Dr. 
Gamache did not think plaintiff's complaints constituted an 
emergency. 
 
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Plaintiff's condition continued to deteriorate.  He had 
difficulty walking, and he lost his fine motor skills.  He 
contacted Dr. Gamache's office by telephone, and he informed 
the receptionist that his symptoms had gotten worse.  The 
receptionist told plaintiff that Dr. Gamache could see him in 
two days.  Plaintiff did not accept the appointment because of 
other commitments. 
 
Plaintiff's condition deteriorated even further.  
However, plaintiff did not seek alternative medical attention 
because Dr. Gamache had repeatedly assured him that his 
symptoms were not significant.  Plaintiff's condition became 
worse and subsequently, plaintiff's wife, Anna K. Allen, took 
him to the emergency room of the Mary Washington Hospital in 
Fredericksburg. 
 
Dr. Richard P. Erwin, a neurologist, treated plaintiff 
while he was a patient at the Mary Washington Hospital.  Dr. 
Erwin's physical examination revealed an abnormality below 
plaintiff's neck, and Dr. Erwin immediately suspected that 
plaintiff's spinal cord might have been affected.  Dr. Erwin 
ordered that a magnetic resonance imaging scan (MRI) be taken, 
and the image revealed an inflammation of plaintiff's spinal 
cord.  Dr. Erwin immediately treated plaintiff with high-dose 
steroids, and plaintiff was transferred to the Medical College 
 
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of Virginia Hospitals, where he was diagnosed as having 
transverse myelitis, an inflammation of the spinal cord. 
 
Dr. Michael Jacobs, an internist, testified that the 
health care providers breached the standard of care owed to 
plaintiff because they failed to diagnose his condition in a 
timely manner.  Dr. Douglas Kerr, a neurologist, testified 
that plaintiff, who now suffers from irreparable neurological 
damage, could have had his condition arrested had the 
physicians diagnosed and treated his condition sooner. 
 
Plaintiff presented evidence that he incurred physical 
and emotional damages, including major depression, proximately 
caused by the defendants' acts of medical negligence.  Dr. 
Murry J. Cohen, a psychiatrist who qualified as an expert 
witness, testified that plaintiff suffered from major 
depression, that plaintiff attempted to commit suicide in 
2002, and that this attempt was caused by his physical 
disabilities associated with transverse myelitis. 
Dr. Cohen testified that plaintiff suffered from 
depression, which was caused by major "stressors."  Dr. Cohen 
stated, "I thought it was . . . clearly the fact that he was 
suffering from a very severe, albeit not diagnosed, 
neurological illness that was causing great distress, 
physically and emotionally, and was interfering with his 
functioning down the line.  And it was clear to me that . . . 
 
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without question, that was the major stressor and the major 
precipitant."  Dr. Cohen acknowledged that even though 
plaintiff was dealing with several stressors in his life, 
including his job, financial problems, his marriage, and 
relationships, Cohen described these stressors as minor and 
testified that plaintiff's illness was the major stressor that 
caused his attempt to commit suicide. 
 
Plaintiff presented evidence that his neurological 
deficit is profound, his condition will continue to 
deteriorate, he has incurred in excess of $96,000 in medical 
expenses, he will require future medical care in excess of 
$2,500,000, and he has suffered a loss of earning capacity in 
excess of $1,100,000. 
 
The jury returned a verdict in favor of plaintiff against 
Dr. Gamache and her employer, Mid-Atlantic Health Care 
Alliance, in the amount of $6,500,000.  The jury returned a 
verdict in favor of defendant, Dr. Powell, and he is no longer 
a party to this proceeding.  Pursuant to Code § 8.01-581.15, 
the circuit court reduced the jury's verdict to $1,550,000 and 
entered a judgment confirming the verdict.  Defendants appeal. 
III. 
A. 
 
Defendants asserted in the circuit court, and argue in 
this Court, that evidence of Mrs. Allen's alleged use of 
 
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narcotics and alleged acts of self-mutilation were relevant 
because the jury could have inferred that plaintiff's 
attempted suicide was caused by these alleged acts instead of 
defendants' negligence.  Continuing, defendants contend that 
the circuit court abused its discretion when it prohibited 
them from eliciting this testimony on the basis that the 
probative value of the evidence was outweighed by its 
prejudicial effect. 
 
Responding, plaintiff states that defendants were allowed 
to introduce evidence of alternative causes of plaintiff's 
depression and suicide attempt, such as his financial 
problems, difficulties with his job, marital strife, and that 
the circuit court did not abuse its discretion when it 
prohibited defendants from eliciting the challenged evidence. 
 
Evidence that is factually relevant may be excluded from 
the jury's consideration if the probative value of that 
evidence is substantially outweighed by the danger of unfair 
prejudice.  Walker v. Commonwealth, 258 Va. 54, 68, 515 S.E.2d 
565, 573 (1999); Coe v. Commonwealth, 231 Va. 83, 87, 340 
S.E.2d 820, 823 (1986).  In determining whether evidence 
should be admitted, the circuit court must apply a balancing 
test to assess the probative value of the evidence and its 
prejudicial effect.  Dandridge v. Marshall, 267 Va. 591, 596, 
594 S.E.2d 578, 581 (2004); Brugh v. Jones, 265 Va. 136, 140, 
 
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574 S.E.2d 282, 284-85 (2003).  Gray v. Graham, 231 Va. 1, 10, 
341 S.E.2d 153, 158 (1986).  This determination, however, 
rests within the sound discretion of the circuit court and 
will only be disturbed on appeal upon a showing of an abuse of 
discretion.  Dandridge, 267 Va. at 596, 594 S.E.2d at 581; 
Lombard v. Rohrbaugh, 262 Va. 484, 492, 551 S.E.2d 349, 353 
(2001); Burns v. Commonwealth, 261 Va. 307, 332, 541 S.E.2d 
872, 889 (2001); Walker, 258 Va. at 68, 515 at 573; Ingles v. 
Diveley, 246 Va. 244, 250, 435 S.E.2d 641, 644 (1993). 
 
Applying these principles, we hold that the circuit court 
abused its discretion by refusing to permit defendants to 
elicit evidence that plaintiff's depression and attempted 
suicide may have been related to his wife's alleged acts of 
narcotics abuse and alleged acts of self-mutilation.  The jury 
was entitled to consider this evidence, which was relevant, 
even though this evidence may be potentially damaging to 
plaintiff. 
In the context of the record before this Court, the 
probative value of the challenged evidence is not 
substantially outweighed by the danger of unfair prejudice to 
plaintiff.  Plaintiff presented evidence, as an element of his 
damages, that the defendants' acts of negligence proximately 
caused his attempt to commit suicide.  The defendants, 
therefore, are entitled to present evidence that other 
 
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significant events that occurred in plaintiff's life for which 
defendants were not responsible were the proximate cause of 
plaintiff's attempted suicide.  And, even though, as plaintiff 
asserts, the jury was aware of alleged alternative causes of 
his depression and suicide attempt, the jury was not aware of 
defendants' allegations that plaintiff's wife purportedly 
abused his narcotic medications and that she purportedly 
engaged in acts of self-mutilation. 
 
We disagree with plaintiff's contention that this 
challenged evidence is collateral.  Plaintiff presented 
evidence that his suicide attempt was caused by the 
defendants' acts of negligence, and he introduced in evidence 
the cost of medical treatment associated with the treatment 
necessitated by the suicide attempt.  The excluded evidence is 
not collateral, but it is relevant to an element of damages 
that plaintiff claimed was proximately caused by defendants' 
acts of negligence.  See Seilheimer v. Melville, 224 Va. 323, 
327, 295 S.E.2d 896, 898 (1982). 
B. 
 
Defendants sought to present evidence that two 
physicians, Dr. Erwin and Dr. Barbara Newberg, who had treated 
plaintiff previously, did not believe that he was trustworthy.  
Defendants also wanted to elicit evidence that one of 
plaintiff's former physicians terminated the patient/physician 
 
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relationship with plaintiff because he had not been truthful 
with that physician.  Defendants contend that the circuit 
court abused its discretion by failing to permit them to 
present this evidence to the jury.   
 
We disagree with the defendants.  Essentially, the 
defendants sought to challenge plaintiff's veracity by 
presenting evidence that he had been untruthful with his 
former physician.  When a litigant impeaches a witness' 
reputation for truth and veracity, such evidence must be 
confined to the general reputation of the impeached witness 
for truth and veracity and may not include the commission of 
specific acts of untruthfulness or other bad conduct, even 
though these have bearing on veracity.  Bradley v. 
Commonwealth, 196 Va. 1126, 1133, 86 S.E.2d 828, 833 (1955); 
Allen v. Commonwealth, 122 Va. 834, 840, 94 S.E.2d 783, 785 
(1918); Langhorne v. Commonwealth, 76 Va. 1012, 1019 (1882). 
 
The circuit court properly refused to permit the 
defendants to present evidence of plaintiff's veracity.  
Defendants sought to present evidence of specific alleged acts 
of untruthfulness, contrary to this Court's well-established 
precedent. 
C. 
 
Dr. Cohen testified on behalf of the plaintiff.  Among 
other things, Dr. Cohen discussed plaintiff's depression, 
 
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attempted suicide, and symptoms, including plaintiff's 
physical pain.  During the defendants' cross-examination of 
Dr. Cohen, the following colloquy occurred: 
"Q:  Is it important that the patient be 
forthcoming with you when giving a history? 
 
"A:  Yes. 
 
"Q:  And you indicated on direct examination 
that you did not think that Mr. Allen exaggerated 
his pain; correct? 
 
"A:  I did not think that; correct. 
 
"Q:  Or you do not think that? 
 
"A:  I do not think that; correct. 
 
. . . . 
 
 
"Q:  [D]o you believe he has always given you a 
full and credible history?  
 
"A:  No.  I haven't always believed that. 
 
. . . . 
 
 
"Q:  Has he given you any information that was 
inconsistent with either information you had heard 
otherwise or your clinical examination of the 
patient? 
 
"[Plaintiff]:  Objection, Your Honor, based on 
previous rulings in this case.  That's not something 
that − the Court has already ruled that's not coming 
in. 
 
"[Defendants]:  I think the door has been 
opened.  He stated on direct . . . that he does not 
believe he's exaggerated his pain.  And this doctor 
has said that he's not believed to have always given 
a full and credible history.  I think this is ripe 
for exploration. 
 
"[The Court]:  I do not believe he used that.  
Objection is sustained." 
 
Defendants argue that the circuit court abused its discretion 
when it limited the scope of defendants' cross-examination of 
Dr. Cohen.  We disagree. 
 
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The circuit court did not abuse its discretion by 
limiting the scope of defendants' cross-examination.  Dr. 
Cohen's statement that plaintiff failed to consistently 
provide Dr. Cohen with a full and credible history simply does 
not contradict Dr. Cohen's observations of plaintiff's pain or 
statements that plaintiff may have made to Dr. Cohen regarding 
the extent of plaintiff's pain. 
D. 
 
In February 2003, plaintiff was taken to the emergency 
room at the Mary Washington Hospital in Fredericksburg.  He 
had a decreased level of consciousness and "pinpoint pupils."  
Dr. Erwin testified that use of narcotics can cause pinpoint 
pupils and decreased awareness.  Hospital personnel performed 
a urine drug screen test on plaintiff's urine sample, and the 
test identified the presence of opiates in plaintiff's body.  
Opiates are narcotic pain medicines.  Defendants contend that 
they were entitled to present expert opinion testimony from 
Dr. Erwin and Dr. Newberg that plaintiff's hospitalization in 
February 2003 was the result of a second suicide attempt.  We 
will not consider this argument because defendants did not 
present an adequate record to this Court, having failed to 
make a proffer of any opinions that Dr. Erwin and Dr. Newberg 
would have rendered. 
IV. 
 
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Plaintiff presented evidence that supports the jury's 
findings that defendants Dr. Gamache and her employer, Mid-
Atlantic Health Alliance, breached the standard of care owed 
to him.  Defendants' assignments of error do not challenge the 
jury's findings that defendants were negligent.  Therefore, 
upon retrial, these findings will be binding upon the 
defendants, and plaintiff will not be required to establish 
that the defendants were negligent.  Plaintiff will only be 
required to establish proximate causation and damages.  Also, 
upon retrial, defendants will be permitted to present evidence 
of plaintiff's wife's alleged acts of narcotics abuse and 
self-mutilation. 
 
Accordingly, we will affirm that portion of the judgment 
that confirmed the jury's findings that the defendants were 
negligent.  We will remand this case for a new trial limited 
to the issues of proximate causation and damages. 
Affirmed in part, 
reversed in part, 
                                         and remanded. 
 
JUSTICE LACY, with whom JUSTICE KINSER joins, concurring in 
part and dissenting in part. 
 
 
I concur in the majority's conclusions regarding 
presentation of evidence of Allen's veracity, the cross-
examination of Dr. Cohen, and opinion testimony of Drs. Erwin 
and Newberg; however, I respectfully dissent from the 
 
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majority's conclusion that the trial court's refusal to allow 
evidence that Mrs. Allen allegedly abused narcotics and 
engaged in self-mutilation was reversible error. 
 
The majority opinion recites that defendants argued that 
Mrs. Allen's alleged use of narcotics and alleged acts of 
self-mutilation "caused" plaintiff's suicide attempt.  Based 
on this characterization, the majority opinion concludes that 
defendants were entitled to present evidence that such acts 
"were the proximate cause of plaintiff's attempted suicide."  
(Emphasis added.)  The record, however, contains no instance 
in the trial court in which the defendants asserted that Mrs. 
Allen's alleged acts were the proximate cause of Mr. Allen's 
suicide attempt. 
At trial, defendants argued that the evidence at issue 
should have been admitted because it showed that the wife's 
actions were "one of the main motivations for [Allen's] 
suicide attempt," that Allen's neurological condition "was not 
his main reason for attempting suicide," and that Mrs. Allen's 
abuse of narcotics was "one of the reasons" Allen attempted 
suicide. 
Defendants' opening brief before this Court states that 
at the hearing on Allen's motion in limine Gamache argued that 
Mrs. Allen's actions "contributed to" Allen's stress and 
suicide attempt.  Defendants also assert on brief that the 
 
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evidence at issue should have been admitted to show that "a 
major reason for Allen's suicide attempt" was Mrs. Allen's 
alleged narcotic abuse and self-mutilation.  In their reply 
brief, the defendants argue that the jury should have had this 
evidence "to determine whether or not Gamache's treatment of 
[Allen] 18 months prior was the proximate cause of the suicide 
attempt."  And had the jury had this evidence, "they could 
well have concluded that Allen was untruthful when he laid all 
the responsibility for his actions at Gamache's feet." 
 
At no time did the defendants argue that Mrs. Allen's 
actions were the proximate cause of Allen's suicide attempt.  
Every argument made refers to Mrs. Allen's acts as additional 
causes of the attempted suicide; there was no argument 
presented that the defendants' negligence was not a proximate 
cause.  Indeed, Allen did not argue that Gamache's negligence 
was the cause of his suicide attempt.  Rather, Allen argues 
such negligence was one of the causes. 
A fundamental tenet of Virginia tort law holds that a 
party is responsible for injuries caused by his negligence 
even if the acts of others contributed to the injuries unless 
those other acts constituted an intervening, superseding cause 
of the injury.  Coleman v. Blankenship Oil Corp., 221 Va. 124, 
131, 267 S.E.2d 143, 147 (1980); Von Roy v. Whitescarver, 197 
Va. 384, 393, 89 S.E.2d 346, 352 (1955).  Applying the 
 
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position taken by the defendants on this issue throughout 
these proceedings, Mrs. Allen's acts as "a major reason," "one 
of the reasons," or "one of the main reasons" for Allen's 
suicide attempt, were only a proximate cause of Allen's 
injuries resulting from his suicide attempt.  Mrs. Allen's 
alleged actions would not negate Gamache's negligence as a 
proximate cause of Allen's injuries.  Accordingly, I conclude 
that the failure to admit the evidence in issue was harmless 
error and I would affirm the judgment of the trial court in 
its entirety.