Case Title: GARNETT v. COYLE

Citation: 

Docket Number: 

State: wyoming

Court: Wyoming Supreme Court

Date: 2001-10-11T00:00:00Z

Document:
GARNETT v. COYLE2001 WY 9433 P.3d 114Case Number: 00-319Decided: 10/11/2001

OCTOBER TERM, A.D. 2001

                                        

KERRY 
GARNETT, 

Appellant(Plaintiff),

v.

JOHN 
COYLE, D.O., 

Appellee(Defendant).

Representing 
Appellant: 

            
Kerry 
Garnett, Pro Se.

 Representing 
Appellee: 

            
Kathleen 
B. Dixon of Murane & Bostwick, LLC, Casper, Wyoming.

  

Before 
LEHMAN, C.J., and GOLDEN, HILL, and VOIGT, JJ., and PARK, 
D.J.

  
            
VOIGT, Justice.

 [¶1]      This is an appeal 
from a summary judgment granted to the appellee, Dr. John Coyle (Dr. 
Coyle).  The district court found 
that the appellant, Kerry Garnett (Garnett), had (1) failed properly to plead 
the allegations necessary to sustain a 42 U.S.C. § 1983 action; (2) failed to 
establish a prima facie case to sustain a violation of his civil rights 
under the Eighth Amendment; and (3) failed to set forth prima facie 
evidence to sustain a medical malpractice claim.

[¶2]      Finding no error 
in the district court's determination that there are no genuine issues of 
material fact and that Dr. Coyle is entitled to judgment as a matter of law, we 
affirm.

STANDARD 
OF REVIEW

[¶3]      Summary judgment 
motions are determined under the following language from W.R.C.P. 
56(c):

The 
judgment sought shall be rendered forthwith if the pleadings, depositions, 
answers to interrogatories, and admissions on file, together with the 
affidavits, if any, show that there is no genuine issue as to any material fact 
and that the moving party is entitled to a judgment as a matter of 
law.

[¶4]      The purpose of 
summary judgment is to dispose of suits before trial that present no genuine 
issue of material fact.  Moore v. 
Kiljander, 604 P.2d 204, 207 (Wyo. 1979).  Summary judgment is a drastic remedy 
designed to pierce the formal allegations and reach the merits of the 
controversy, but only where no genuine issue of material fact is present.  Weaver v. Blue Cross-Blue Shield of 
Wyoming, 609 P.2d 984, 986 (Wyo. 1980).  A fact is material if proof of that fact 
would have the effect of establishing or refuting one of the essential elements 
of a cause of action or defense asserted by the parties.  Schuler v. Community First Nat. 
Bank, 999 P.2d 1303, 1304 (Wyo. 2000).  The summary judgment movant has the 
initial burden of establishing by admissible evidence a prima facie case; 
once this is accomplished, the burden shifts and the opposing party must present 
specific facts showing that there is a genuine issue of material fact.  Boehm v. Cody Country Chamber of 
Commerce, 748 P.2d 704, 710 (Wyo. 1987); 
Gennings v. First Nat. Bank of Thermopolis, 654 P.2d 154, 156 (Wyo. 
1982).

[¶5]      This Court 
reviews a summary judgment in the same light as the district court, using the 
same materials and following the same standards.  Unicorn Drilling, Inc. v. Heart 
Mountain Irr. Dist., 3 P.3d 857, 860 (Wyo. 2000) (quoting Gray v. Norwest 
Bank Wyoming, N.A., 984 P.2d 1088, 1091 (Wyo. 1999)).  The record is reviewed, however, from 
the vantage point most favorable to the party who opposed the motion, and this 
Court will give that party the benefit of all favorable inferences that may 
fairly be drawn from the record.  
Garcia v. Lawson, 928 P.2d 1164, 1166 (Wyo. 1996).  Mere inferences, conclusions, and 
assertions are not sufficient to defeat summary judgment.  McClellan v. Britain, 826 P.2d 245, 247 (Wyo. 1992); 
Mayflower Restaurant Co. v. Griego, 741 P.2d 1106, 1113 (Wyo. 1987) 
(quoting Stundon v. Sterling, 736 P.2d 317, 318 (Wyo. 1987)); 
Blackmore v. Davis Oil Co., 671 P.2d 334, 336-37 (Wyo. 1983) (quoting 
Gennings, 654 P.2d at 155).

[¶6]      Summary judgment 
is not favored in a negligence action and is, therefore, subject to more 
exacting scrutiny.  Woodard v. 
Cook Ford Sales, Inc., 927 P.2d 1168, 1169 (Wyo. 1996).  This is particularly true in malpractice 
suits.  DeHerrera v. Memorial 
Hospital of Carbon County, 590 P.2d 1342, 1345 (Wyo. 1979) (quoting Holl 
v. Talcott, 191 So. 2d 40, 46 (Fla. 1966)).  We have, however, affirmed summary 
judgment in negligence cases where the record failed to establish the existence 
of a genuine issue of material fact.  
See Krier v. Safeway Stores 46, Inc., 943 P.2d 405 (Wyo. 
1997) (failure to establish duty); Popejoy 
v. Steinle, 820 P.2d 545 (Wyo. 1991) (failure of proof of underlying claim of 
a joint venture); MacKrell v. Bell H2S Safety, 795 P.2d 776 (Wyo. 
1990) (failure of proof of defendant's duty); 
DeWald v. State, 719 P.2d 643 (Wyo. 1986) (cause element was pure speculation); and 
Fiedler v. Steger, 713 P.2d 773 (Wyo. 1986) (failure to establish cause in a medical 
malpractice action).

DISCUSSION

[¶7]      Garnett is a 
long-term prisoner in the Wyoming State Penitentiary (WSP).  Dr. Coyle provides medical care at WSP 
through Correctional Medical Services, Inc. (CMS).  Garnett's allegations in this case are 
(1) cruel and unusual punishment resulting from Dr. Coyle's "repeated and 
intentional acts of deliberate indifference" to Garnett's "serious medical 
needs;" and (2) the endangerment of Garnett's health and safety through Dr. 
Coyle's "intentional and deliberate acts of malpractice."  At issue is Dr. Coyle's treatment of 
Garnett for carpal tunnel syndrome (CTS).

[¶8]      The salient facts 
of the case must be gleaned from the materials filed in support of, and in 
opposition to, the motion for summary judgment.  Dr. Coyle filed the following relevant 
items:

            
1.         
Affidavit of John Coyle, D.O.

            
2.         
CV of John Coyle, D.O.1

            
3.         
Wyoming State Penitentiary Inmate Medical Records, Kerry 
Garnett

            
4.         
Correctional Medical Services Formulary  
Analgesics

            
5.         
Affidavit of Brenda Powers, RN

            
6.         
Affidavit of Paul Ruttle, M.D.

            
7.         
CV of Paul Ruttle, M.D.

            
8.         
Supplemental Affidavit of John Coyle, D.O.

            
9.         
Supplemental Affidavit of Paul Ruttle, M.D.

            
10.       
Rebuttal Affidavit of Paul Ruttle, M.D.

In 
response, Garnett filed the following items:

            
1.         
Nerve Conduction Study

            
2.         
Health Services Request Form

            
3.         
Infirmary Admission Record

            
4.         
Consultation Reports

            
5.         
Physician's Orders

            
6.         
Progress Notes

            
7.         
Dictated Notes of Dr. Schulze

            
8.         
Discharge Summary

            
9.         
Operative Report

            
10.       
Discharge Instructions

            
11.       
Lay In

            
12.       
Medication Administration Report, September 1999

13.      NCCHC (National 
Commission on Correctional Health Care) Standards "P-01  Access to 
Care"

14.      NCCHC Standards 
"P-15  Environmental Health and Safety"

15.      NCCHC Standards 
"P-38  Sick Call"

16.      NCCHC Standards 
"P-42  Patient Transport"

17.      NCCHC Standards 
"P-52  Infirmary Care"

18.      Wyoming 
Department of Corrections Medical Care Contract

19.      Informal 
Grievance dated June 23, 1999

20.      Formal Grievance 
dated June 28, 1999

21.      Formal Grievance 
Acknowledgment dated June 29, 1999

22.      Formal Grievance 
Amendment dated July 14, 1999

23.      Formal Grievance 
Appeal dated August 1, 1999

24.      Informal 
Grievance dated August 8, 1999

25.      Formal Grievance 
dated August 11, 1999

26.      Formal Grievance 
Acknowledgment dated August 12, 1999

27.      Informal 
Grievance dated August 17, 1999

28.      Informal 
Grievance Answer dated August 18, 1999

29.      Formal Grievance 
dated August 22, 1999

30.      Formal Grievance 
Answer dated September 3, 1999

31.      Grievance Appeal 
Answer dated September 8, 1999

32.      Informal 
Grievance dated September 8, 1999

33.      Letter to 
Associate Warden Jerry Steele dated September 9, 1999

34.      Letter to 
Associate Warden Jerry Steele dated September 10, 1999

35.      Formal Grievance 
dated September 13, 1999

36.      Formal Grievance 
Acknowledgment dated September 17, 1999

37.      Informal 
Grievance Answer dated September 17, 1999

38.      Grievance Appeal 
dated October 18, 1999

39.      Affidavit of 
Kerry Garnett

40.      Affidavit of 
Merrill Ayers

41.      Affidavit of 
Merrill Ayers

42.      Affidavit of Mark 
Farnham

43.      Affidavit of Todd 
Brock

44.      Letter from Lori 
Gorseth  Attorney General's Office

45.      Letter from Dr. 
Kenneth Schulze

46.      Documented 
refusal to attend dangerous surgical procedure

[¶9]      Garnett began 
suffering from left arm and wrist pain as early as 1996.  Dr. Coyle began working at WSP in April 
1999.  In that same month, Dr. Coyle 
examined Garnett and referred him to Dr. Schulze, an orthopedic surgeon in 
Rawlins, for evaluation for possible CTS.  
Dr. Schulze recommended nerve conduction studies, which were approved by 
Dr. Coyle, and which were performed by Dr. McMahon, a neurologist in 
Lander.  Dr. Coyle reviewed Dr. 
McMahon's report on May 18, 1999.

[¶10]   In late June 1999, Garnett 
submitted a standard form for additional health services.  He was seen on June 30, 1999, by the 
nursing staff, who scheduled an appointment for Garnett with Dr. Coyle on July 
14, 1999.  Dr. Coyle examined 
Garnett on the latter date.  
Believing that Garnett's symptoms might be caused by something other than 
CTS, Dr. Coyle recommended cervical stretching exercises for six to eight 
weeks.2

[¶11]   The nursing staff again saw Garnett 
on July 20, 1999, and August 8, 1999.  
For purposes of summary judgment review, we accept Garnett's assertions, 
as did the district court, that Dr. Coyle refused to see him for a "period of 
time" during this interval.3  As can be seen from the list of exhibits 
Garnett submitted in opposition to summary judgment, he filed numerous informal 
and formal grievances during this period complaining of the delay since 1996 and 
his current inability to see Dr. Coyle.  
On August 10, 1999, Dr. Coyle again reviewed Garnett's records, and on 
August 17, 1999, Dr. Coyle referred Garnett to Dr. Schulze, this time for a 
surgical consultation.  On August 
23, 1999, Dr. Schulze recommended CTS surgery for Garnett's left wrist.  The next day, Dr. Coyle ordered the 
surgery.  The surgery was performed 
successfully on September 7, 1999.4

[¶12]   Garnett's grievances did not end 
with the surgery.  For purposes of 
his summary judgment motion, we will assume as true Garnett's additional 
complaints that Dr. Coyle changed the surgeon's pain medication recommendation 
from Percocet to Darvocet, that Garnett did not receive the antibiotics 
prescribed by the surgeon, that Garnett was not given the incentive spirometer 
he was supposed to use after surgery, and that he did not receive the throat 
lozenges he requested for pain resulting from the surgical breathing 
tube.

[¶13]   CTS generally is a one-day 
procedure and patients do not typically receive post-hospital professional 
care.  WSP's infirmary policy, 
however, required Garnett to stay in the infirmary for one day after 
surgery.  Because his infirmary room 
was unclean, Garnett objected to being placed there.  When informed of the situation, Dr. 
Coyle responded that he did not "have time for this," and did nothing about the 
room's condition.  Garnett then told 
Dr. Coyle he "would be sorry" for making him stay there, adding "if you leave me 
in this filthy room, I'm taking your stupid ass to court."

[¶14]   Garnett was seen by an RN and Dr. 
Coyle the day after his surgery.  He 
had normal left hand sensations and movement, and he made no complaints of 
nausea, vomiting or other medication side effects.  The following day, September 9, 1999, he 
was seen by Dr. Schulze, who "reordered" antibiotics, use of the incentive 
spirometer and pain medication.  For 
purposes of the summary judgment motion, the district court assumed as true 
Garnett's statement that by September 10, 1999, he was complaining that the pain 
medication was making him ill.  The 
medical records show no such complaint until nearly midnight on September 11, 
1999.  When informed the next 
morning of Garnett's complaints, Dr. Coyle changed Garnett's pain medication to 
Tylenol or Advil.

[¶15]   Beginning on September 15, 1999, 
Garnett's care was handled by a physician's assistant, Jeff Deiss, P.A. 
(Deiss).  Deiss removed the sutures 
from Garnett's incisions, noting no signs of infection, with good healing, 
sensation, color and movement.  
Deiss saw Garnett again on September 17, 1999, and September 20, 
1999.  Garnett's final follow-up 
appointment with Dr. Schulze revealed normal left hand function, reduced pain 
and "marked improvement" of the symptoms that necessitated the surgery.  Garnett recovered fully from the 
surgery, with no complications.

            
The Civil Rights 
Claims

[¶16]   42 U.S.C. § 1983 (Cum.Supp. 2001) 
provides, in pertinent part:

Every 
person who, under color of any statute, ordinance, regulation, custom, or usage, 
of any State . . ., subjects or causes to be subjected, any citizen of the 
United States or other person within the jurisdiction thereof to the deprivation 
of any rights, privileges, or immunities secured by the Constitution and laws, 
shall be liable to the party injured in an action at law, suit in equity, or 
other proper proceeding for redress . . ..

[¶17]   This statute creates a federal 
cause of action for damages to vindicate violations of federal law committed by 
persons acting "under color of state law."  
Jojola v. Chavez, 55 F.3d 488, 492 (10th Cir. 
1995).  To establish a 42 U.S.C. § 1983 claim, a 
plaintiff must demonstrate (1) that he has been deprived of a right secured by 
the Constitution and laws of the United States; and (2) that the alleged 
deprivation was committed by a person acting under color of state law.  D.T. by M.T. v. Independent School 
Dist. No. 16 of Pawnee County, Okl., 894 F.2d 1176, 1186 (10th 
Cir.), cert. denied, 498 U.S. 879 (1990).5

[¶18]   Specifically, Garnett claims that 
Dr. Coyle violated his right under the Eighth Amendment to be free from "cruel 
and unusual punishment."  A 
prisoner's treatment and the conditions of imprisonment are subject to Eighth 
Amendment scrutiny.  Helling v. 
McKinney, 509 U.S. 25, 31, 113 S. Ct. 2475, 2480, 125 L. Ed. 2d 22 
(1993).  In that regard, "deliberate 
indifference to serious medical needs of prisoners' violates the [Eighth] 
Amendment because it constitutes the unnecessary and wanton infliction of pain 
contrary to contemporary standards of decency."  Helling, 509 U.S.  at 32 
(quoting Estelle v. Gamble, 429 U.S. 97, 104, 97 S. Ct. 285, 291, 50 L. Ed. 2d 251 (1976), cert. denied, 434 U.S. 974 (1977)).  It follows that a plaintiff must show 
both "deliberate indifference" and "serious medical needs."  Estelle, 429 U.S.  at 104, 
106.  The first test is subjective, the second 
objective.  Handy v. Price, 
996 F.2d 1064, 1067 (10th Cir. 1993) (quoting Miller v. Glanz, 
948 F.2d 1562, 1569 (10th Cir. 1991)).

[¶19]   A showing of negligence, indeed 
even gross negligence, does not amount to a showing of "deliberate 
indifference."  Estelle, 429 U.S.  at 106; 
Archie v. City of Racine, 847 F.2d 1211, 1219 (7th Cir. 1988), 
cert. denied, 489 U.S. 1065 (1989).  The plaintiff must show that the 
defendant knew of a substantial risk of serious harm to the plaintiff and still 
refused medical assistance.  
Farmer v. Brennan, 511 U.S. 825, 834, 114 S. Ct. 1970, 128 L. Ed. 2d 811 (1994).

"[The 
test for deliberate indifference] affords considerable latitude to prison 
medical authorities in the diagnosis and treatment of medical problems of inmate 
patients.  Courts will disavow any 
attempt to second-guess the propriety or adequacy of a particular course of 
treatment . . . [which] remains a question of sound professional judgment.'  Bowring v. Godwin, 551 F.2d 44, 
48 (4th Cir.1977).  
Implicit in this deference to prison medical authorities is the 
assumption that such an informed medical judgment has, in fact, been made.  When, however, prison authorities 
prevent an inmate from receiving recommended treatment for serious medical needs 
or deny access to a physician capable of evaluating the need for such treatment, 
the constitutional standard of Estelle has been 
violated."

Gomm v. 
DeLand, 729 F. Supp. 767, 779 (D.Utah 1990), aff'd, 931 F.2d 62     (10th Cir. 
1991) (quoting Inmates of Allegheny County Jail v. Pierce, 612 F.2d 754, 
762 (3rd Cir. 1979)).

[¶20]   To state a prima facie case 
of "deliberate indifference" under the Eighth Amendment, a plaintiff must show 
inaction that is equivalent to intentional or criminally reckless 
misconduct.  Estelle, 429 U.S.  at 104, 106.  A difference of opinion over medical 
treatment, or a refusal to provide requested treatment does not, without more, 
show "deliberate indifference."  
Riddle v. Mondragon, 83 F.3d 1197, 1202-04 (10th Cir. 
1996); 
Handy, 996 F.2d  at 1067.  Where some medical attention has been 
afforded, a dispute over the adequacy of the treatment sounds, at most, in state 
tort law, and is not of constitutional magnitude.  Gomm, 729 F. Supp.  at 
780.

[¶21]   In addition to "deliberate 
indifference," the plaintiff must also show that such indifference was directed 
to a "serious medical need."  
"Because society does not expect that prisoners will have unqualified 
access to health care, deliberate indifference to medical needs amounts to an 
Eighth Amendment violation only if those needs are "serious."  . . ..'"  Riddle, 83 F.3d  at 1204 
(quoting Hudson v. McMillian, 503 U.S. 1, 9, 112 S. Ct. 995, 1000, 117 L. Ed. 2d 156 (1992)).  "Serious medical needs" are those 
diagnosed by a physician as mandating treatment or those that are so obvious 
that even a lay person would easily recognize the necessity for a doctor's 
attention.  Riddle, 83 F.3d  
at 1202 (quoting Ramos v. Lamm, 639 F.2d 559, 575 (10th Cir. 1980), cert. denied, 450 U.S. 1041 
(1981)).

[¶22]   The totality of the evidence 
contained in the summary judgment materials in the instant case reveals that 
there are no genuine issues of material fact and that Dr. Coyle is entitled to 
judgment as a matter of law on the Eighth Amendment claim.  The affidavits and medical records 
clearly show a successful course of treatment afforded to Garnett.  At most, Garnett's materials show only 
some delay in having the surgery, coupled with relatively minor post-surgical 
treatment complications.  Most of 
the delay between Garnett's visit with Dr. Coyle on July 14, 1999, and the 
surgery on September 7, 1999, was occasioned by the fact that Dr. Coyle wanted 
to pursue a less aggressive treatment plan until he was sure that CTS was the 
problem and that surgery was warranted.  
Garnett had been complaining of left arm and wrist pain for three 
years.  Ironically, within five 
months of Dr. Coyle's appearance on the scene, surgery had been 
performed.

[¶23]   Once a prima facie case of 
appropriate medical treatment was shown, the burden shifted to Garnett to 
establish both prongs of the Eighth Amendment test:  "deliberate indifference" and "serious 
medical needs."  Neither was 
shown.  From the evidence, it may be 
inferred that Dr. Coyle did not always give his immediate and full attention to 
Garnett's complaints.  But there is 
no evidence of the level of culpability required to sustain such a claim.  Further, the record reveals that 
Garnett's treatment was at least as good as that available to non-inmates.  His post-surgical attention, in 
particular, exceeded the norm in that it lasted longer and involved more pain 
medication than would usually follow CTS release.  Dr. Coyle's less-than-enthusiastic 
responses to Garnett's demands do not rise to the level of "deliberate 
indifference" to Garnett's condition for Eighth Amendment purposes.  And the expert opinions contained in Dr. 
Coyle's and Dr. Ruttle's affidavits make it clear that no "serious medical 
needs" of Garnett were ignored.  In 
fact, the incentive spirometer was unnecessary, since Garnett was immediately 
ambulatory, the antibiotic was contra-indicated, since routine antibiotic 
administration can lead to its ineffectiveness, and Darvocet is preferred over 
Percocet because it is less addictive.

            
Medical 
Malpractice

[¶24]   There are four elements to a cause 
of action for medical malpractice, which elements largely track the elements of 
a cause of action for negligence:

            
1.         
The accepted standard of medical care or practice 
(duty).

            
2.         
That the physician's conduct departed from that standard 
(breach).

            
3.         
That the plaintiff was injured (damages).

            
4.         
That the physician's conduct caused the injuries 
(cause).

Oakden 
v. Roland, 988 P.2d 1057, 1059 (Wyo. 1999) (quoting Harris v. Grizzle, 625 P.2d 747, 751 (Wyo. 1981)); 
Apodaca v. Ommen, 807 P.2d 939, 943 (Wyo. 1991).  In addition, Wyo. Stat. Ann. § 1-12-601 
(LexisNexis 2001) provides, in part:

            
(a)       
In an action for injury alleging negligence by a health care provider the 
plaintiff shall have the burden of proving:

            
(i)         
If the defendant is certified by a national certificating board or 
association, that the defendant failed to act in accordance with the standard of 
care adhered to by that national board or association; or

            
(ii)        If 
the defendant is not so certified, that the defendant failed to act in 
accordance with the standard of care adhered to by health care providers in good 
standing performing similar health care services.

The 
determination of the standard of care imposed upon a defendant in a medical 
malpractice case is a question of law for the judge rather than a question of 
fact for the jury.  Roybal v. 
Bell, 778 P.2d 108, 111 (Wyo. 1989).  Expert medical testimony is generally 
required to establish a physician's failure to meet the standard of care.  Oakden, 988 P.2d  at 1059 
(quoting Harris, 625 P.2d at 752-53); 
Sayer v. Williams, 962 P.2d 165, 168 (Wyo. 1998) (quoting Harris, 
625 P.2d at 752-53).

[¶25]   While the plaintiff in a medical 
malpractice action generally carries the burden of proof on these issues, a 
defendant doctor who has moved for summary judgment must first establish a 
prima facie case of non-negligence.  
In the instant case, Dr. Coyle produced his own expert opinion and the 
expert opinion of an orthopedic surgeon as to the standard of care in a case of 
this nature and as to Dr. Coyle's having met that standard of care.  Garnett produced no expert medical 
testimony in response.6  Instead, he attempted to rely on 
language in the contract between WSP and CMS, and upon standards promulgated by 
the NCCHC.  In making that attempt, 
Garnett failed to establish sufficient foundation for these "standards," and he 
presented no expert testimony that the standards are in effect, or how they 
should be applied.

[¶26]   Like his Eighth Amendment claim, 
Garnett's medical malpractice claim must fail.  There are no genuine issues of material 
fact, and Dr. Coyle is entitled to judgment as a matter of law.  Garnett did not establish the applicable 
standard of care or a breach of that standard by Dr. Coyle.  On the other hand, in support of his 
motion, Dr. Coyle established through expert opinion testimony both the standard 
of care and the fact that he had not breached that 
standard.

[¶27]   Affirmed.

FOOTNOTES

  1A "CV" is a 
resume; "CV" stands for curriculum vitae.

  
2Specifically, 
Dr. Coyle reasoned that the absence of wrist-related neurological deficits 
indicated Garnett may have been suffering from cervical radiculopathy rather 
than CTS.

  3All "facts" set 
forth herein are stated in the light most favorable to 
Garnett.

  
4In a letter and 
a memorandum, both dated September 8, 1999, Department of Corrections Director 
Judith Uphoff and Health Services Administrator Jim Davis notified Garnett that 
the delays described in his grievances were a "scenario * * * unacceptable to 
the Department of Corrections," but the situation would be considered resolved 
as a result of the surgery finally having been 
performed.

   5The district 
court considered Garnett's civil rights claims under 42 U.S.C. § 1983 despite 
the fact that Garnett did not even cite to the statute in his complaint.  Because 42 U.S.C. § 1983 is the proper 
vehicle to assert such a cause of action, we will follow the district court's 
lead.

  6Garnett argues 
that Dr. Coyle was negligent because he did not immediately agree with Dr. 
McMahon's CTS diagnosis.  In that 
sense, the "Nerve Conduction Study" identified as his Exhibit No. 1 in his 
response to Dr. Coyle's motion for summary judgment, which is Dr. McMahon's 
report, might be considered expert evidence.  But Garnett produces no evidence of any 
kind, expert or otherwise, to suggest that it was malpractice for Dr. Coyle to 
postpone the CTS surgery and to first attempt the more conservative approach of 
stretching exercises.