Title: Kobos By and Through Kobos v. Everts

State: wyoming

Issuer: Wyoming Supreme Court

Document:

Kobos By and Through Kobos v. Everts1989 WY 17768 P.2d 534Case Number: 86-12Decided: 01/17/1989Supreme Court of Wyoming
MICHAEL 
ROBERT KOBOS, A MINOR CHILD TWO YEARS OF AGE, BY AND THROUGH MICHAEL KOBOS AND 
REBECCA KOBOS, HIS PARENTS AND NEXT FRIENDS; MICHAEL KOBOS AND REBECCA KOBOS, 
APPELLANTS (PLAINTIFFS),

 
 
v.

 
 
CHARLES 
EVERTS, M.D.; RICHARD G. SUGDEN, M.D.; KENNETH L. LAMBERT, M.D.; KENNETH L. 
LAMBERT, M.D., P.C., A WYOMING PROFESSIONAL CORPORATION; TETON RADIOLOGY 
ASSOCIATES, P.C., A WYOMING PROFESSIONAL CORPORATION; JAMES R. LITTLE, M.D.; 
THOMAS POCKAT, M.D.; JACKSON PEDIATRICS, P.C., A WYOMING PROFESSIONAL 
CORPORATION; JOHN DOES I-X; AND DOE PARTNERSHIPS, CORPORATIONS AND/OR OTHER 
ENTITIES I-X, APPELLEES (DEFENDANTS).

 
 
Appeal from 
the District Court, TetonCounty, John D. Troughton, 
J.

 
 
Lawrence B. 
Hartnett, Jackson, for 
appellants.

 
 
J.E. 
Vlastos of Vlastos, Brooks & Henley, P.C., Casper, for appellees Everts and Teton 
Radiology Associates, P.C.

 
 
Frank D. 
Neville and Michael Golden of Williams, Porter, Day & Neville, P.C., 
Casper, for appellee 
Sugden.

 
 
Paul B. 
Godfrey of Godfrey, Sundahl & Jorgenson, Cheyenne, for appellee 
Lambert.

 
 
Carl L. 
Lathrop of Lathrop, Rutledge & Boley, Cheyenne, for appellee 
Little.

 
 
Lawrence A. 
Yonkee of Redle, Yonkee & Arney, Sheridan, for appellee 
Pockat.

 
 
Before CARDINE, C.J., THOMAS, URBIGKIT and MACY, 
JJ., and BROWN,* J., 
Retired.

 
 

* Retired 
June 30, 1988.

 
 

URBIGKIT, 
Justice.

 
 

[¶1.]     Presented for appellate 
review is a six week medical malpractice trial against five physicians involving 
claims of improper hip treatment of osteomyelitis and septic arthritis of a one 
year old child, which resulted in verdicts in favor of four defendants and 
directed verdicts for all. The issues encompass excluded witnesses, denied 
cross-examination, directed verdicts and contended erroneous negligence 
instruction.

 
 

[¶2.]     We reverse and remand 
for retrial.

 
 
I. 
ISSUES

 
 

[¶3.]     Although variously 
stated by appellants and the five separate appellees who are differently 
affected, the appellate issues presented include: 

 
 
                        
1. Basic medical malpractice negligence 
instruction;

 
 
                        
2. Directed verdict for the radiologist;

 
 
                        
3. Subsequent directed verdicts for other appellees after they secured a 
favorable jury 
verdict;

 
 
                        
4. Trial court decision denying appellants the right to call the appellee 
doctors as adverse witnesses during their case in chief; 
and

 
 
                        
5. Contested witness exclusion and evidentiary decisions of the trial 
court:

 
 
                        
a. Limitation on testimony of appellants' expert radiologist to consider 
standard of care as contributory to the injury sustained;

 
 
            
            
b. Limitation of testimony of expert witnesses regarding standard of care 
of radiologist which was rejected either as cumulative or not 
competent;

 
 
                        
c. Denied use of Michael Lagios, M.D. as an expert witness on the basis 
that his testimony would be cumulative; and

 
 
                        
d. Denied use of Lawrence Madoff, M.D. as an expert witness on the basis 
that his testimony would be cumulative.

 
 
II. 
FACTS

 
 

[¶4.]     Appellants include 
Michael Robert Kobos, a young child, and his parents of Jackson, Wyoming. In 1981, as the date of these events, 
the one year old developed a right hip pain. The patient was first evaluated in 
office and through telephone contact by Jackson doctors, James R. Little, M.D. and 
associate intern, Thomas J. Pockat, M.D. With the young child's condition 
producing "essentially normal x-rays," he was then seen by a general 
pediatrician, appellee Richard G. Sugden, M.D., whose office was in the same 
building as Dr. Little's. Consultation followed with yet another doctor, 
appellee Kenneth L. Lambert, M.D., a Jackson orthopedic surgeon. In this period of 
regular examinations as the child's problem continued, x-rays were taken and 
reviewed by appellee radiologist Charles Everts, M.D., with the continued 
finding of an essentially normal condition for the medical 
evaluation.

 
 

[¶5.]     After about two and 
one-half months of this course of action with care limited to continuous office 
visits and no improvement, medical reference was made by Dr. Sugden for the 
child to be evaluated at the University of Utah Medical Center in Salt Lake City, Utah. The serious condition as diagnosed in 
Utah required apparent surgery, which was done 
by return to Jackson and performed by Dr. William Mott. 
Following surgery, the diagnosis was made of chronic osteomyelitis (infected 
bone).

 
 

[¶6.]     As a result of either a 
developmental infected bone condition or surgical misadventure by Dr. Mott, 
growth plate damage resulted to the femur which will bring about significant 
future hip growth and use problems for the child. The broad character of factual 
issues considered at trial was whether the delayed medical attention while the 
infected bone condition developed precipitated the recognized injury or whether 
Dr. Mott, in final curative surgery, caused the permanent injury damage during 
the surgical process. Consequently in litigative approach, appellees denied 
diagnosis delay or treatment fault and blamed Dr. Mott as the surgeon who 
operated. The record of the lengthy trial can be summed up as including 
complicated evidence and a significant number of expert witnesses. Qualification 
of appellants' expert witnesses at trial was particularly painstaking in time, 
detail and opposition.

 
 
III. PROPER 
INSTRUCTION

 
 

[¶7.]     A principal issue in 
this appeal is appellants' challenge to the instructions, which included 
Instruction No. 18 as subject to the most detailed objection at trial and upon 
appeal. Instruction No. 18 states:

 
 
            
You are instructed that physicians and surgeons are not liable for mere 
errors of judgment, provided there has been a careful examination and ordinary 
care and skill has been exercised.

 
 
     In other words, if, 
from all the evidence it appears by a preponderance that the acts or omissions 
of the defendants, each or all of them, upon which plaintiffs' claims are 
predicated clearly involved and constituted an exercise of an honest judgment, 
arrived at after careful and necessary investigation, and

 
 
     a. The judgment is 
approved by a respectable portion of competent and reputable physicians or 
surgeons in the same line of practice, and

 
 
     b. There is nothing to 
indicate that the approval is not honestly made, or that the approval, the 
judgment or the acts or omissions are unreasonable,

 
 

[¶8.]     Then, the defendants, 
each or all of them, are not liable.1

 
 

[¶9.]     Appellants assert that 
Instruction No. 10 was a correct articulation of the law and that Instruction 
No. 18 was improper as contrary to Vassos v. Roussalis, 625 P.2d 768 (Wyo. 1981) 
(Vassos I) and Vassos v. Roussalis, 658 P.2d 1284 (Wyo. 1983) (Vassos II). We 
agree.

 
 

[¶10.]  In Vassos I, 625 P.2d  at 772-73, as 
recognizing that a malpractice action is usually a form of negligence 
litigation, this court observed:

 
 
[T]he 
existence of the physician-patient relationship established the duty. The 
standard is fixed as that which is required of a reasonable person in light of 
all the circumstances. * * * A malpractice contention is also one of those 
circumstances. The more specific standard for malpractice actions is that a 
physician or surgeon must exercise the skill, diligence and knowledge, and must 
apply the means and methods, which would reasonably be exercised and applied 
under similar circumstances by members of his profession in good standing and in 
the same line of practice. * * *

 
 
     The skill, diligence, 
knowledge, means and methods are not those "ordinarily" or "generally" or 
"customarily" exercised or applied, but are those that are "reasonably" 
exercised or applied. Negligence cannot be excused on the grounds that others 
practice the same kind of negligence. Medicine is not an exact science and the 
proper practice cannot be gauged by a fixed rule. * * * * * * such circumstances 
are not of such common knowledge, the jury must depend upon testimony of experts 
to explain the standard and thus prevent a conclusion based on conjecture and 
speculation. * * * In other words, an additional question of fact must be 
answered when the circumstances are such that the reasonable person standard is 
not within the common knowledge of the jury.

 
 

[¶11.]  Furthermore, strict adherence to the 
so-called locality rule is not appropriate. DeHerrera v. MemorialHospital of CarbonCounty, 590 P.2d 1342 (Wyo. 1979); Vassos II, 658 P.2d 1284. We 
cannot accommodate acceptance of the instruction given within the criteria of 
the Vassos rule after the timely objection at trial that the instruction would 
confuse or mislead the jury as to the appropriate principle of law. Cervelli v. 
Graves, 661 P.2d 1032 (Wyo. 1983). The phraseology given simply does 
not define a duty of due care but bespeaks in responsibility to moral decision 
and honesty, and as the principal instruction, constitutes reversible error. 
Intent is not a factor of negligence since negligence precludes intended 
conduct. Globe Indem. Co. v. Blomfield, 115 Ariz. 5, 562 P.2d 1372 (1977); 65 C.J.S. Negligence § 3 at 
473 (1966); W. Prosser & W. Keeton, The Law 
of Torts § 31 at 169 (5th ed. 1984).

 
 

[¶12.]  A leading authority has been identifiable 
within the Wyoming criterion which provides that there 
are two applicable standards of care to be applied in malpractice 
cases.

 
 
The first, 
which was correctly charged, holds the doctor to the standard of care measured 
by the knowledge and ability of the average physician or specialist in good 
standing in the community where he practices. This is the standard of reasonable 
care. Liability is premised upon the failure to exercise reasonable care, so 
measured. A doctor is also subject to a separate duty which requires him to use 
his best judgment, but which does not make him liable for mere error in 
judgment, provided he does what he thinks is best after careful examination. * * 
* "An error of judgment charged is appropriate in a case where a doctor is 
confronted with several alternatives and, in determining the appropriate 
treatment to be rendered, exercises his judgment by following one course of 
action in lieu of another."

 
 
1 S. 
Pegalis and H. Wachsman, American Law of Medical Malpractice § 2:9 at 69, 71-72 
(1980) (quoting Pike v. Honsinger, 155 N.Y. 201, 49 N.E. 760 (1898)). It is 
noteworthy where a careful examination is given and clear alternative treatment 
courses exist, that an error of judgment charge may additionally be appropriate. 
Appellants were entitled to contend that the alternatives were not embraced in 
this case since, generally speaking, nothing was done during the critical period 
as medical treatment which effectively addressed the physical problem as later 
disclosed by x-ray analysis and surgical intervention.

 
 
The 
instructions must be considered as a whole in order to determine whether the 
instructions as a whole are fair. But the introductions must clearly reflect the 
factual situation presented in the case as well as the applicable 
law.

 
 
1 D. 
Louisell and H. Williams, Medical Malpractice § 11.38 at 11-134 (1988) 
(footnotes omitted). The test of standard of care in a malpractice case is 
ordinary skill and diligence as possessed by members of the profession 
generally. "Reasonable and ordinary care, skill, and diligence" is the test 
denominated in 4 Reid's Branson Instructions to Juries, ch. 146, § 2442 at 473 
(1987 Cum.Supp.). See similarly, PIK 2d 15.01 at 66 (2d ed. 1977) (although 
continuing to include some category of the locality rule). It is apparent that 
there is a difference in the concepts of the law between a bad result achieved 
with care and a less than careful bad choice. Excluding the Wyoming deleted locality 
rule, the Illinois Pattern Jury Instructions properly 
inform:

 
 
In 
[treating] * * * a patient, a [doctor] * * * must possess and apply the 
knowledge and use the skill and care that is ordinarily used by reasonably 
well-qualified [doctors] * * * in similar cases and circumstances. A failure to 
do so is a form of negligence that is called malpractice.

 
 
IPI 2d 
105.01 at 319 (1971).

 
 
     A physician's conduct 
* * * must be measured against what a physician having and using that knowledge, 
skill and care of physicians practicing in the same field of practice in the 
same or similar locality at the same time would or would not do under the same 
or similar circumstances.

 
 
CJI 2d 15:2 
at 313 (1988). The mere error in judgment criteria as relied upon by the trial 
court for instruction comes from Wright v. Conway, 34 Wyo. 1, 241 P. 369 (1925). 
That concept is now subsumed within the modernized standards for present day 
professional practitioners invoking skill, diligence, knowledge, and application 
of means and methods reasonable under the circumstances by persons within the 
profession. Clearly, as we specifically stated in Vassos I, 625 P.2d  at 772, 
"[n]egligence cannot be excused on the grounds that others practice [or approve 
of] the same kind of negligence." Under the misdiagnosis non-action thesis of 
appellants' claims of negligence, the jury instruction was 
improper.

 
 
IV. DENIAL 
OF RIGHT TO CALL APPELLEES AS ADVERSE WITNESSES IN APPELLANTS' CASE IN 
CHIEF

 
 

[¶13.]  During trial, appellants were advised by 
the trial court, at a point which, as a consequence, was near the end of their 
case in chief, that:

 
 
     You will not be 
permitted to call the Defendant Doctors as adverse witnesses because it's the 
judgment of this Court if they are called for direct examination and you have 
the opportunity to cross-examine on the substance of their testimony, this case 
is going to go faster. That's based not only upon my experience, in general, 
that that is a quicker way to handle adverse parties but it's also based upon 
what I've observed in this courtroom concerning what's happened in this 
courtroom with respect to individual witnesses.

 
 
     You think the Court is 
unreasonable. The Court believes that the length of examination of most of the 
witnesses in this case has been unreasonable and that a good deal of time could 
have be[en] saved with respect to - could have be[en] saved with examination and 
cross-examination that was more directed and to the point.

 
 
Early the 
following week, the decision was reiterated:

 
 
     Now, for the record, 
the Court indicated last week that it would not allow the Plaintiffs to call the 
Defendants during their case in chief and would require the Defendants to put 
them on the stand. Now, the reason that the Court did that is because the 
testimony in the case is going slow. It was the Court's considered opinion that 
the testimony would go quicker if the direct examination brought out the 
testimony of the doctors, leaving the Plaintiffs with the right to 
cross-examine. And that that would go quicker in the considered opinion of the 
Court because the Court is of the opinion based upon several weeks of trial and 
several weeks of experience with witnesses that are either perceived as being 
adverse by the Plaintiffs or are adverse witnesses, in fact, to the Plaintiffs, 
that during cross-examination in Plaintiffs' case, the examination has gone 
slowly because Plaintiffs' Counsel finds himself in the position during the 
presentation of his case in chief of wanting to elicit from the adverse parties 
the testimony that is important to his case in chief but to avoid the testimony 
of the adverse parties, which is more related to the defense and which is 
adverse to the case in chief. And because the Court perceives that Counsel finds 
themselves in that position, Counsel perceives - or the Court perceives Counsel 
as going very slowly and carefully, attempting to avoid during his case in 
chief, the unfavorable aspects of the testimony of the adverse parties. In the 
attempts to avoid those unfavorable aspects, the examination goes slowly. The 
Court, in its judgment, thought that if the adverse nature of the testimony is 
laid out on the table quickly, that Counsel would then be - would be alleviated 
- or the problem that Counsel faces of trying to avoid that testimony would be 
alleviated because it would be out on the table and Counsel would not have to be 
so careful but could just come in and the whole process would go 
quicker.

 
 

[¶14.]  The subject was again reanalyzed by the 
trial court after all other case in chief witnesses had been called as then 
closing that trial segment with continued adverse examination 
denial:

 
 
     Well, it's very 
doubtful at this stage of the game that the Defendants are not going to be 
called to the stand. We'll know that after we handle the motions. Okay. So let's 
handle - We'll deal with the testimony of the Defendant Physicians offered in 
Plaintiffs' case in chief at the same time that we deal with the motions for 
directed verdict that are going to be made this morning. In other words, if it 
appears that testimony of the Defendant Doctor is going to be critical to any 
motion for a directed verdict insofar as the Plaintiff is concerned, then the 
Court is in a position of dealing with that by allowing that Doctor to be 
called. If it's not critical, then the Court can stand by its previous ruling 
that we'll do the * * * direct examination and you get your crack at them 
through cross-examination.

 
 

[¶15.]  The status of the issue on appeal is 
problematical since although discussed, it is not generally addressed as a 
designated issue for appeal and is contested by only Dr. Everts in argument. 
None of the litigants in appellate brief have furnished citations that a trial 
court can or cannot, as a matter of discretion, generally deny to plaintiff the 
right to call an opposing party as an adverse witness. Cf. Hall v. Hall, 708 P.2d 416 (Wyo. 
1985), cited by appellants. In anticipation that the problem will not reoccur on 
retrial, this court need not presently explore whether any circumstance could 
occur which would justify this kind of a general restriction on trial 
development by a litigant.2

 

V. DIRECTED 
VERDICT FOR RADIOLOGIST

 
 

[¶16.]  Without being afforded the opportunity to 
call the physician radiologist as an adverse witness to determine what his 
activities and function may have been, the trial court granted a directed 
verdict in his behalf at the close of appellants' evidence. Thereafter, in 
appellees' case after trial court announcement of the directed verdict, the 
ex-litigant testified as an expert witness in behalf of the other appellees.3 In consideration of appellants' 
evidence and cross-examination, the trial court justified by oral explanation to 
the attorneys why he would grant the directed verdict:

 
 
And when 
you look at all of the evidence with respect to Dr. Everts in that sense and in 
that light, then the Court concludes that the evidence, in the light most 
favorable to the Plaintiffs, establishes that not only did Dr. Everts not fail 
to properly read x rays but that evidence, at best, establishes that it was a 
judgment call for Dr. Everts. The beauty is in the eye of the beholder, so to 
speak.

 
 
     Now, finally, the 
testimony clearly is that you can't diagnose osteomyelitis or septic hip in this 
case from the x rays. At least not the x rays - I can say it that way. You can't 
diagnose this by the x rays. You can diagnose changes but you cannot tell what 
the changes are. And even if one were to conclude that there were changes on 
October 14 and 15 at the time of the last x ray plate and the last bone scan of 
Dr. Everts, the evidence in the light most favorable to the Plaintiffs indicates 
that in order to diagnose septic hip and osteomyelitis, something more had to be 
done. And so even if there was a failure to properly read those two radiology 
materials, there's no evidence of any direct, proximate cause between that 
failure and the injuries that the Plaintiffs contend occurred, those injuries 
being from osteomyelitis and septic hip which was not treated, which conditions 
cannot be diagnosed by x rays.

 
 

[¶17.]  Intrinsic to appellants' case was 
evidentiary discussion of the duty of the radiologist to examine and report 
which is encompassed within a standard of due care to his patient. In earlier 
discussion before the directed verdict had been granted, the trial court had 
analyzed:

 
 
     It would appear to the 
Court in this case that the uncontradicted evidence of all of the experts is 
that Dr. Everts had no duty to diagnose; that he had no duty to 
treat.

 
 
This 
characterization of the duty or lack thereof of the radiologist is directly 
contrary to common reasoning (to determine what may be seen) and contrary to 
general precedent. Clayton v. Thompson, 475 So. 2d 439, 442 (Miss. 1985) (quoting Hall v. Hilbun, 466 So. 2d 856 
(Miss. 
1985)):

 
 
[E]very 
doctor "has a duty to use his or her knowledge and therewith treat through 
maximum, reasonable, medical recovery, each patient, with such reasonable 
diligence, skill, competence, and prudence as are practiced by minimally 
competent physicians in the same specialty or general field of practice throughout the United States, who have 
available to them the same general facilities, services, equipment and options." 
[Emphasis in original.]

 
 
[P]roximate 
cause arises when the omission of a duty contributes to cause the injury. 
Gardner v. 
National Bulk Carriers, Inc., 310 F.2d 284 (4th Cir. 1962) cert. denied, 372 U.S. 913, 83 S. Ct. 728, 9 L. Ed. 2d 721 (1963). Harvey v. Silber, 300 Mich. 510, 2 N.W.2d 483 (1942). "Proximate 
cause here is implicit in the breach of duty. Indeed, the duty would be empty if 
it did not itself embrace the loss as a consequence of its breach." Gardner, supra, at page 
287.

 
 

Id. at 445. We 
agree with appellants' position with reference to Vassos II, 658 P.2d 1284 that 
whether a duty exists and the scope of that duty are questions of law for the 
court. Id. at 
1287. We would also agree with case law and text authority that radiologists 
have responsibilities to patients and to other physicians which are similar to 
those of pathologists - accurate diagnosis. 1 D. Louisell and H. Williams, 
supra, at § 3.23 at 3-82. See also, Keen v. Prisinzano, 23 Cal. App. 3d 275, 100 Cal. Rptr. 82 (1972). Factually, the circumstance that after x-rays were taken in 
the Salt Lake City clinic and immediate medical attention found to be required, 
belies adequacy of the earlier care given to the patient by the Jackson 
radiologist to the extent at least that a question of fact for the jury was 
created. DeHerrera, 590 P.2d 1342.

 
 

[¶18.]  As an early witness, appellants called 
Dr. Maurice O'Connor who, after initial medical school graduation, spent time in 
general practice, then military service, and thereafter was trained for 
specialization in diagnostic radiology. While in that pursuit, he also graduated 
from law school and has since described his activity as 75% to 80% in pure 
medicine in the diagnostic radiology specialty and 20% to 25% or less in 
forensic medicine. Extended, detailed, and continued objection started from the 
first and continued to the last of his testimony during the two and one-half day 
session while he was a witness. The principal attack came by denial of appellees 
that the witness could properly state an opinion that the medical diagnosis for 
the small child should have come sooner and the treatment should have been 
better in regard to the service by all appellee witnesses. In broad category, 
the type of inquiry that developed has since been addressed by this court in 
Oukrop v. Wasserburger, 755 P.2d 233 (Wyo. 1988).

 
 

[¶19.]  Despite those constant objections by 
appellees, Dr. O'Connor specifically testified that in his opinion the standard 
of performance of radiologist Dr. Everts fell below the standard of appropriate 
care. An attempt was further denied in examining the witness to connect 
described insufficiency of radiology service by cause to the later discovered 
hip condition. In sustaining latter objections, the trial court stated that 
"[t]he Jury doesn't need assistance from an expert in that area. The objection 
is sustained." Subsequently, the following question was 
asked:

 
 
Well, for 
the record, I have to ask you to put back on your radiologist hat and tell me 
whether you have an opinion as to whether or not the failure of Dr. Charles 
Everts as a radiologist to meet the standard of care required of him had any 
causal relation to the condition in Mikey Kobos' hip which ultimately resulted 
as you've described it on these films?

 
 
The 
question was answered yes, and the requested opinion floundered on a lack of foundation objection as well as 
competency as sustained. Inquiry of 
counsel followed and the trial court responded:

 
 
     THE COURT: Do you want 
me to tell you on the record, in front of the Jury?

 
 
     MR. ANDREW HARTNETT: 
Beg your pardon?

 
 
     THE COURT: Do you want 
me to tell me [sic] on the record?

 
 
     MR. ANDREW HARTNETT: 
May be I would rather you tell me off-the-record, out of the presence of the 
Jury.

 
 
     THE COURT: Okay. Then 
let's just leave it where it sits.

 
 

[¶20.]  The thesis of the trial court was then 
later explained by the previously quoted order granting the directed verdict. 
Essentially, the record presents a legal determination in divergence with the 
factual record as to the responsibility of the medical doctor practicing in the 
specialty of radiology. The trial court denied to appellants the intrinsic 
expert witness opinion to completely define the standard of care 
required.

 
 

[¶21.]  It is noteworthy how appellee Dr. Everts 
in brief describes the radiologist's participation in the medical 
practice:

 
 
Everts read 
or interpreted the plain x-ray films and the bone scan films. In this regard 
Everts submitted written reports which are a part of the hospital records or 
chart. The actual procedure in taking the films, both the plain films and the 
bone scan films, is done by technicians and not by Everts. This is the usual 
method or procedure in taking and interpreting radiological tests or procedures. 
Everts did not see or touch Michael Kobos with respect to the plain films and 
did not actively participate in the procedure generating the bone scan films. 
Several of the exhibits offered by Appellants include copies of the reports of 
Everts; however, the same are within the hospital chart/record (Exhibit 2). The 
plain x-ray films are designated Exhibits 9-1 through 9-22 and the bone scan 
films are designated as Exhibits 11-7 through 11-10.

 
 
     Therefore, the 
involvement of Everts consists entirely of his interpretation of the plain x-ray 
films taken on September 9, September 15, and October 14, and the bone scan 
films made on October 15, 1981.

 
 

[¶22.]  Surprisingly, it is questioned that Dr. 
Everts owed a duty to the patient. Clearly, that contention should not be in 
factual dispute from this record or within today's medical world. If the 
physician performing the service for a patient expects to be paid, he has the 
duty of a doctor to his patient. Dr. Everts was a doctor and Kobos was his 
patient for radiology purposes. Really at issue was due care of the medical 
practitioner. When the directed verdict was granted, the witness provided by 
appellants of unquestioned competence and medical experience had on this record 
testified adversely (to the extent permitted) as to compliance with that due 
care standard.

 
 

[¶23.]  Both the duty of the radiologist to make 
and adequately communicate a correct diagnosis is discussed in Phillips v. Good 
Samaritan Hospital, 65 Ohio App.2d 112, 416 N.E.2d 646, 649 (1979), where 
summary judgment was reversed as that court said:

 
 
Weighing 
the facts and competing inferences, as we must, in a light most favorable to the 
party opposing summary judgment, it is possible to find the existence of a 
causal relationship between a breach of duty and the injury suffered. * * * Once 
the physician-patient relationship has been found to exist, as could well be 
found here, the professional responsibilities and duties exist despite the lack 
of proximity, or the remoteness, of contact between the two as where a 
consulting physician is involved in the case in only a limited manner. 
Therefore, all physicians involved in a case share in the same duties and 
responsibilities of the primary care physician to the extent of their 
involvement.

 
 

[¶24.]  It would seem in characterization that 
the ship had slipped sails somehow for directed verdict to be granted after the 
expert testimony had been given that the radiologist in performing a service of 
examining and reporting on x-rays did not meet the required standard of 
performance. An issue of negligence was presented. See a detailed analysis of 
liability, Clayton, 475 So. 2d 439.

 
 

[¶25.]  Appellants' problem with medical 
testimony relating to the radiologist's standard of care did not yet end. Called 
as a principal witness for appellants was San Francisco, California orthopedic surgeon, Dr. Kevin 
Harrington. After inquiry developed by examination of when appellants started to 
present the opinion of the witness in regard to the standard of care of the 
radiologist, a very extensive in camera discussion followed after which the 
trial court ruled in open court statement to the jury:

 
 
Ladies and 
Gentlemen of the jury. The Court has ruled that Dr. Harrington shall not be 
permitted to express an opinion, either directly or indirectly, concerning 
whether the x-ray and bone scan analysis done by Dr. Everts was negligent or 
careless or whether it was careful and prudent. Any further testimony by Dr. 
Harrington shall not be viewed or considered by you as applicable to the 
standard of care required of Dr. Everts. Dr. Lambert's objection at the 
testimony of Dr. Harrington to the effect that Dr. Lambert should have read the 
bone scan, himself, is without foundation and has been sustained by the 
Court.

 
 
What this 
meant in trial procedure by trial court ruling was that the orthopedic surgeon 
was not competent to express an opinion about x-rays, which would also serve to 
isolate that doctor from responsibility whether or not the radiologist had made 
a mistake. Furthermore, this standard of medical practice would establish that 
the orthopedic practitioner had no independent responsibility to utilize his 
knowledge of x-rays in patient diagnosis and treatment.4

 
 

[¶26.]  Finally, from the standpoint of 
appellants as the developments worsened in character, objection was taken to the 
way this trial evolution was to be orally presented to the 
jury:

 
 
     My concern is that any 
such instruction to the Jury, in and of itself, intends to reflect on the 
credibility of Dr. Harrington and is additionally prejudicial to the Plaintiffs 
case and that no instruction at this point in the evidence is necessary at all. 
He has not expressed an opinion regarding Dr. Everts nor has he expressed an 
opinion as to the failure of Dr. Lambert in any way in his interpretation. He is 
qualified to read them and interpret them himself and the instruction would be 
grossly prejudicial to the Plaintiffs.

 
 
The 
expressed concern was not without unjustified substance in case progression as a 
trial development. We conclude that the restriction on the witness' testimony 
was unjustified and constitutes an abuse of discretion.5

 
 
 VI. OTHER ISSUES 
PRESENTED

 
 

[¶27.]  In determination that a retrial is 
required, we would only consider other issues to the extent that a reoccurrence 
of question might again develop.

 
 
a. Directed Verdicts Granted to Drs. Sugden, 
Lambert, Little and Pockat After the Entry of Defendants' Jury 
Verdict.

 
 

[¶28.]  The considerable discussion of this issue 
by the litigants does not present any justiciable question for us to now 
determine. The case was submitted to the jury, which would not now presently 
justify our decision on a subsequent directed verdict after favorable verdict. 
We would, however, observe that citations to cases involving a judgment 
notwithstanding the verdict are misplaced, since a judgment notwithstanding the 
verdict is directed to adversely attack the verdict and not to serve as a 
compatible substitute. See Baker v. Helms, 527 So. 2d 1241, 1243 (Ala. 1988) for 
evidentiary test. In concluding that this particular problem will not likely 
reoccur upon retrial, a further review becomes unjustified since this result 
with another favorable verdict could not call for application of W.R.C.P. 50(b). 
Mayflower Restaurant Co. v. Griego, 741 P.2d 1106 (Wyo. 1987); Simpson v. Western Nat. Bank of Casper, 497 P.2d 878 (Wyo. 1972). 

 
 

[¶29.]  The significance in perspective to 
appellants is only relative to the topic of the excluded medical witnesses as 
being "cumulative." The problem is presented of the trial court's decisions that 
first the testimony of expert witnesses on violated standards of care is 
cumulative, and then without the support of appellants' case by the proposed 
expert opinion testimony to foreclose recovery by directed verdict on the basis 
of insufficiency of proof.6

 

b. Denied Testimony of Tendered 
Witnesses.

 
 

[¶30.]  Appellants challenge the denial of 
tendered testimony to be elicited from three proposed witnesses. Appellants had 
planned to present expert testimony from Dr. Lawrence Madoff and Dr. Michael 
Lagios in addition to the adverse examination of the appellees. Both witnesses 
had been deposed by appellees at appellees' convenience pursuant to specific 
trial court order. Dr. Lagios was a pathologist at Children's Hospital in 
San Francisco, California and Dr. Madoff, a pediatrician. 
Originally, pretrial objection had been taken to the late designations. Then 
after being deposed by trial court order following a change in trial judges, the 
objection to trial presentation was sustained on the basis that their medical 
opinion testimony "would be cumulative." The issue of late designation will not 
reoccur with a new trial, and consequently, its tortuous pathway in this 
extended record will not be pursued. Our consideration of the cumulative issue 
as an exercise of discretion is colored by the subsequent decision of the trial 
court after verdict that a directed verdict emplacing inadequate proof was 
proper. We are also distressed in present decision by incomplete opportunity to 
evaluate the prospective testimony as "cumulative," since by its very nature, it 
would have been relevant and material if admissible. Under any circumstance in 
the contextual development of this case with the categorization pursued by 
counsel and the trial court, it would appear that with an appellee pediatrician 
and with other pediatricians listed as expert witnesses for the defense, that 
app effort to present a pediatrician expert witness to establish a standard of 
care and its violation would not likely be cumulative. Additionally, the 
relevance of the pathologist to contest testimony of a pathologist who placed 
the blame on the succeeding surgeon, Dr. Mott, seems extraordinarily confined. 
With retrial, the cumulative nature of prospective inquiry should be more 
clearly delineated by the record if rejection reoccurs.

 
 

[¶31.]  From this record, support for the 
exclusion criteria carefully defined in Towner v. State, 685 P.2d 45 (Wyo. 1984) is not 
established. This court there said that "Rule 403 [W.R.E.] is an extraordinary 
remedy which should be used sparingly since it allows the court to exclude 
evidence which is concededly relevant and probative." Id. at 49. In the instant 
case, where two of the appellee doctors were pediatricians and appellants were 
disallowed the right to call a pediatrician as an expert witness, that rationale 
is hard to justify. Discretion, in any event, has its limits as we said in 
Martin v. State, 720 P.2d 894, 897 (Wyo. 1986):

 
 
     Judicial discretion is 
a composite of many things, among which are conclusions drawn from objective 
criteria; it means a sound judgment exercised with regard to what is right under 
the circumstances and without doing so arbitrarily or 
capriciously.

 
 

[¶32.]  In a medical malpractice case, plaintiff 
requires expert testimony for proof. Harris v. Grizzle, 625 P.2d 747 (Wyo. 1981). Denial of the 
pathologist's testimony is similarly questionable where the defense is postured 
on an approach to lay the blame onto the operating surgeon by defendant's 
pathological testimony. Availability of the tendered witness to plaintiff is 
similarly required to permit the litigant to have the same opportunity to have 
eleven men on the field of play. At the least, all witnesses reasonably 
available to provide substantive evidence should have been permitted to testify 
before the trial court executes or at least exiles plaintiffs' case to a never 
to be land. The general law is in accord. See United States v. Davis, 639 F.2d 239 (5th Cir. 1981), cited by 
this court with approval in Towner, 685 P.2d  at 49, where evidence was 
"independent corroborative testimony on a material issue." See likewise 2 D. 
Louisell and C. Mueller, Federal Evidence § 128 at 68 (1985). As is stated in J. 
Weinstein & M. Berger, Weinstein's Evidence § 403[06] at 403-95, 403-99 
(1986):

 
 
     Certainly, Rule 403 
does not mean that a court may exclude evidence that will cause delay regardless 
of its probative value. If the evidence is crucial, the judge would abuse his 
discretion in excluding it.

 
 

[¶33.]  In a case surprisingly similar as 
involving denied testimony of a pediatrician witness, the court in Johnson v. 
United States, 780 F.2d 902 (11th Cir. 1986) reversed the trial court's decision 
and plaintiff's verdict when the witness was to testify for defendant. Quoting 
Weinstein with approval, the appellate court found the trial court's action to 
be an abuse of discretion. The testimony of the expert witness had been excluded 
as cumulative when presented to support the expert testimony of two other 
witnesses in the death case. The appellate court considered that the litigant 
had the right, in this case the United States government under the 
federal Tort Claims Act, to present testimony which was more comprehensive and 
at least partially non-cumulative through use of a pediatrician to testify in 
opposition to pediatricians who were presented by the 
plaintiff.

 
 

[¶34.]  The involved principles are 
well-stated:

 
 
     Not all evidence which 
is entirely duplicative is therefore cumulative and excludable. Evidence may 
vary in degree of persuasiveness, and when an item of proof which is offered on 
a point is very different in character or persuasive impact from an item of 
proof previously received, the former cannot be considered merely "cumulative" 
of the latter. Moreover, at times it is entirely reasonable for a party to 
insist, "One witness is good, but two or three will make my case much stronger, 
even though all will testify in a similar vein." In short, the discretion of the 
trial judge to exclude cumulative evidence must be exercised in a discriminating 
fashion, and with wisdom, particularly where the evidence in question goes to 
issues of central importance in the case.

 
 
2 D. 
Louisell and C. Mueller, supra at 74-75 (footnote omitted). See Hill v. Bache 
Halsey Stuart Shields, Inc., 790 F.2d 817 (10th Cir. 1986); Bower v. O'Hara, 759 F.2d 1117 (3rd Cir. 1985); and United States v. Fessel, 531 F.2d 1275 (5th Cir. 1976).

 
 

[¶35.]  The trial court retains considerable 
latitude even with admittedly relevant testimony in rejecting evidence which is 
cumulative or in requiring that evidence be brought to the jury's attention in a 
manner least likely to cause confusion. However, the litigant "is entitled to an 
opportunity to adduce relevant, competent evidence bearing on the issues to be 
tried." Hamling v. United 
States, 418 U.S. 87, 125, 94 S. Ct. 2887, 2911-12, 
41 L. Ed. 2d 590, reh'g denied 419 U.S. 885, 95 S. Ct. 157, 42 L. Ed. 2d 129 (1974). 
Thus, evidence which in the context of the litigation is merely repetitious or 
time consuming may be excluded, but only if time consideration substantially 
outweighs the incremental probative value of the proffered evidence. M. Graham, 
Handbook of Federal Evidence § 403.1 at 179 (2d ed. 1986).

 
 

[¶36.]  The denied testimony of proposed witness 
Betty Perkinson (Perkinson) is substantively complex. In compliance with trial 
court orders, appellants had filed, as a notice of an additional witness, 
Perkinson's name. That witness would testify that Jane Fairbanks (Fairbanks), a receptionist 
in the office of Dr. Little, had told her that she had improperly answered 
deposition examination when asked if she recalled the number of times that 
Rebecca Kobos had telephoned the doctor's office. Following designation, 
appellee Dr. Little filed a motion in limine to prohibit Perkinson from being 
called as a witness and the motion was considered during trial and then 
rejected.

 
 

[¶37.]  The sequence of developmental events on 
the issue is interesting. It is indicated in the record, although a copy of a 
deposition is not included, when appellants took the deposition of prospective 
witness Fairbanks as the office secretary for Dr. Little, that the witness 
testified she could not recall how many telephone calls were made to the office 
by the patient's mother during the defined period. As subsequently discovered 
evidence, appellants planned to tender testimony from an acquaintance of the 
witness, Perkinson, as noticed as an unexpected witness who would state that 
Fairbanks, the office secretary, had said to her sometime after the deposition, 
"I lied at my deposition." "The lawyers asked how many times Becky Kobos called 
over a specific period of time." "I told them I didn't know." "I wasn't about to 
help those lawyers." Then to conclude in the conversation between the two women, 
Fairbanks 
related "that woman called one hell of a lot."

 
 

[¶38.]  For in camera trial inquiry, the office 
secretary Fairbanks was examined by appellants, after which a motion in limine 
was granted against use by appellants of any testimony from her which would 
invade the subject of the number of office telephone calls received and also the 
alleged discussion of her deposition testimony on the subject with Perkinson. 
Consequently, appellants contended that if she were to give the same testimony 
before the jury, she would again lie as she did in the deposition. The direction 
of the examination by appellants as denied by the motion in limine was to 
revisit the deposition inquiry of the witness, and if consistent, then impeach 
with subsequent statement of admitted untruth. As first approached by the trial 
court, the motion in limine to the initial inquiry of the office secretary was 
sustained as an attempt to prove the telephone calls through hearsay testimony 
offered under the guise of impeachment. The premise of the denial to appellants 
of this aspect of the examination of Fairbanks is unclear at this juncture on 
appeal. The foundational question for impeachment was excluded by the in limine 
decision as to Fairbanks so that the testimony of Perkinson 
was foreclosed in advance as lacking anything to impeach. The issue problem in 
present posture is found in justification for the motion in limine as limiting 
inquiry of a witness in regard to a prior inconsistent statement.7 If, in fact, that would have been 
her sworn testimony before the jury as consistent with the deposition and 
inconsistent with statements to the acquaintance, then whether the in limine 
evidence would be properly emplaced to impeach as to the fact of the prior 
inconsistent statement would have a more justified structure for issue 
presentation. We need not presently assume how the witness might hereafter 
testify at trial and if she continues a course of denied recollection, whether 
the trial court has discretion to deny impeachment. The truth is to be found in 
either what the witness said in deposition or what the other witness stated she 
subsequently said. We do not find a relevancy question since obviously the 
theory of appellants was to prove parental concern and continued effort to 
secure some more satisfying medical recognition of perceived increasing physical 
problems of their baby boy. Consequently, we do not necessarily determine 
whether the impeachment examination is subject to discretional exclusion by the 
trial court, but do not find a basis submitted for denial to appellants of the 
foundational inquiry of the office secretary.

 
 

[¶39.]  This court had occasion in Channel v. 
State, 592 P.2d 1145 (Wyo. 1979) to consider the impeachment and 
direct evidence issues implicit in W.R.E. 607 and 802. Clear approval for the 
process undertaken by appellants is indicated provided that a subsequent 
limiting instruction is given. In specific decision, what we have here is that 
the trial court determined to protect the office secretary from the "travail" of 
impeachment by being faced with the contention of her later statement that she 
committed perjury in a deposition and then reiterated in the in camera 
examination which indicated her intent to continue that posture for the jury 
presentation. Denial of the opportunity to appellants to establish the 
foundation for the impeachment by the first of two limiting trial court orders 
cannot be justified by direct citation of authorities presented in appellate 
briefs.

 
 

[¶40.]  Detailed review of the prior inconsistent 
statement inquiry in use and function is found in two recent A.L.R. 
annotations.8 It is notable that this court in 
Channel cites the first annotation and then the second annotation cites Channel 
as part of the progressively developing concept that permits use of prior 
inconsistent statements as evidence in defined circumstances. The not dissimilar 
subject of use of hearsay to prove prior statements if the witness is now 
unavailable by lost memory was considered by the United States Supreme Court in 
the 1988 term in approving usage for criminal prosecution, see United States v. 
Owens, 484 U.S. 554, 108 S. Ct. 838, 98 L. Ed. 2d 951 (1988).

 
 

[¶41.]  Although the application in Owens is 
different as involving substantive testimony rather than impeachment, the 
characterization which it afforded is relevant:

 
 
It would 
seem strange, for example, to assert that a witness can avoid introduction of 
testimony from a prior proceeding that is inconsistent with his trial testimony, 
see Rule 801(d)(1)(A), by simply asserting lack of memory of the facts to which 
the prior testimony related.

 
 
Owens, 108 S. Ct.  at 845. The witness here, by statement that she could remember the number 
of telephone calls, was isolated by trial court order from testimony about her 
subsequent comment of deliberate misstatement.

 
 

[¶42.]  Appellees' tailored their defense to the 
impeachment denial decision on an abuse of discretion concept as not clearly 
wrong in citing Waldrop v. Weaver, 702 P.2d 1291 (Wyo. 1985); Brockett v. 
Prater, 675 P.2d 638 (Wyo. 1984); and Bacon v. Carey Co., 669 P.2d 533 (Wyo. 
1983). None of those cases involve impeachment of contended perjurious 
testimony. Canyon View Ranch v. Basin Elec. Power Corp., 628 P.2d 530 
(Wyo. 1981) as 
also cited presents a relevancy question. The one case of somewhat similar 
character, Diamond Management Corp. v. Empire Gas Corp., 594 P.2d 964 (Wyo. 
1979) addresses impeachment denial as harmless error since the compared 
testimony was not essentially dissimilar.

 
 

[¶43.]  The record establishes that the perjury 
contention was a concern that the trial court did not want to be presented to 
the jury - even if true.9 

 
 

[¶44.]  Yet another conflict on testimony is 
presented in this appeal. In cross-examination of Dr. Little, appellants' 
counsel inquired about his experience in the treatment of children who had 
osteomyelitis or septic arthritis. An irrelevancy objection was sustained. The 
inquiry followed an earlier motion to compel discovery which had required the 
doctor to answer questions concerning his treatment of MB, a specific patient 
with a similarly diagnosed condition. The relevancy may be indicated if we were 
to review the documents and file as furnished with discovery, but it is not in 
this record. Without an offer of proof at trial, this record fails to afford us 
a justification for disagreement with the discretional decision of the trial 
court. Assumption of fact in brief are not exchangeable for an adequately 
presented offer of proof in trial. Nicholls v. Nicholls, 721 P.2d 1103 
(Wyo. 1986); Majority of Working Interest 
Owners in Buck Draw Field Area v. Wyoming Oil 
and Gas Conservation Com'n, 721 P.2d 1070 (Wyo. 1986).

 
 

[¶45.]  We reverse and remand for 
retrial.

 
 

CARDINE, C.J., and 
THOMAS, J., filed special 
concurrence opinions.

 
 

BROWN, J., 
Retired, dissented in part and concurred in part and filed an 
opinion.

 
 
FOOTNOTES

 
 

1      Eight other 
specific medical malpractice instructions were given, which included in general 
text:

 
 
            
INSTRUCTION NO. 8

 
 
            
The Plaintiffs contend that Michael Robert Kobos was at different times a 
patient under the care and treatment of each of the Defendant doctors. 
Plaintiffs claim that the Defendants, each or all of them, were negligent in 
their care and treatment of Michael Robert Kobos, which negligence was the 
proximate cause of injuries and damages suffered by 
Plaintiffs.

 
 
                        
Each Defendant denies the Plaintiffs' claim asserted against 
him.

 
 
                        
The Plaintiffs have the burden of proving their claims against each 
Defendant by a preponderance of evidence.

 
 
(The factual basis for 
the denial of patient-doctor status implicit in the instruction is not 
demonstrable from trial evidence.)

 
 
            
INSTRUCTION NO. 9

 
 
            
In this action, the Plaintiffs have the burden of proving by a 
preponderance of the evidence with respect to each Defendant the 
following:

 
 
            
1. The Defendant was negligent; and

 
 
            
2. The negligence of the Defendant was the proximate cause of the injury 
to the Plaintiffs; and

 
 
            
3. The nature and extent of the injuries claimed to have been so 
suffered, the elements of Plaintiffs' damage and the amount 
thereof.

 
 
            
     In 
determining whether an issue has been proved by a preponderance of the evidence, 
you should consider all of the evidence bearing upon that issue regardless of 
who produced it. The existence of such proposition must be more probable than 
its nonexistence. [Emphasis in original.]

 
 
            
INSTRUCTION NO. 10

 
 
            
     
Generally, negligence means the failure to use ordinary 
care.

 
 
            
     
Negligence as that term is used in these instructions with respect to the 
Defendant physicians means the failure to exercise the skill, diligence and 
knowledge, and to apply the means and methods which would reasonably be 
exercised and applied under similar circumstances by members of the profession 
in good standing and in the same line of practice.

 
 
            
     The 
burden is upon the Plaintiffs to show by a preponderance of the evidence that 
each Defendant failed to exercise the degree of care and skill required from 
him.

 
 
            
INSTRUCTION NO. 11

 
 
            
It is the duty of a physician or surgeon who holds himself out as a 
specialist in a particular field of medical, surgical or other healing science, 
to have the knowledge and skill ordinarily possessed, and to use the care and 
skill ordinarily used, by reputable specialists practicing in the same field and 
under similar circumstances.

 
 
            
One who holds himself out as a specialist in that field and who 
undertakes diagnosis or treatment in his specialty is required to use the skill 
and care required of such a specialist.

 
 
            
INSTRUCTION NO. 12

 
 
            
In order to prove negligence, it is necessary for Plaintiffs to prove by 
a preponderance of expert medical testimony that a Defendant doctor failed to 
use the standard of care given to you in the foregoing instructions and such 
failure was a proximate cause of the injury complained of.

 
 
            
INSTRUCTION NO. 13

 
 
            
If the origin of the alleged injuries is obscure and not readily 
apparent, or if there are several equally probable causes of the condition, it 
is the burden of the Plaintiffs to prove by a preponderance, through competent 
expert medical testimony, that among the possible causes of the alleged injuries 
there is a reasonable probability (that is to say, the most likely cause was) 
the negligence, if any, of each Defendant.

 
 
            
INSTRUCTION NO. 16

 
 
            
You are instructed that in rendering medical services to a patient, a 
physician does not impliedly warrant or guarantee the success of his treatment 
or operation. The physician does impliedly warrant that he possesses and will 
exercise such professional skill and learning as are ordinarily possessed by 
medical practitioners practicing in the same field and under similar 
circumstances.

 
 
            
INSTRUCTION NO. 17

 
 
            
The law presumes that a physician or surgeon has carefully and skillfully 
treated or operated on his patient. There is no presumption of negligence from 
the fact of an injury or adverse result. However, this presumption is rebuttable 
and may be overcome by a preponderance of the testimony and evidence which 
establishes negligence or lack of reasonable care on the part of a physician or 
surgeon in his medical diagnosis, his performance of surgical procedures, and 
his care and treatment of patients.

 
 

2 Within the penumbra 
between due process, Boddie v. Connecticut, 401 U.S. 371, 377, 91 S. Ct. 780, 
787, 28 L. Ed. 2d 113 (1971), and reasonable control over the presentation of 
evidence, McCabe v. R.A. Manning Const. Co., Inc., 674 P.2d 699 (Wyo. 1983), any 
restriction on rights of litigants to plan and present their case or for general 
evidentiary exclusion pursuant to W.R.E. 403 should tread 
softly.

 
 

3 Appellants 
characterize the status of the directed verdict for 
Everts:

 
 
     It must be emphasized 
that after Appellee Everts received a directed verdict in his favor he appeared 
at trial as an expert witness for the remaining Appellees, and while still 
glowing with the halo of innocence, damned Dr. William Mott as the cause of 
young Michael Kobos' devastating injuries.

 
 

4 The specific decision 
and ratio decidendi of the trial court was stated to 
counsel:

 
 
The Court notes that 
[prior trial judge] required the Plaintiffs to designate the experts that 
Plaintiffs would require in this case to meet their burden of proof and among 
those experts [was] a radiologist. Also among those experts [was] an orthopedic 
surgeon. Two separate doctors; two separate physicians.

 
 
     The Court, therefore, 
rules under Rule 403 that because the testimony of Dr. Harrington in the area of 
radiology will be cumulative, it will not be received by considerations of undue 
delay and waste of time. If the Supreme Court believes that I have abused my 
discretion in such a discretionary ruling, knowing more about this difficult 
trial than I do sitting in it, losing hair and developing ulcers, then it is the 
ruling of the Court that Mr. Vlastos' objections are sustained. Sustained on the 
basis that there's no foundation indicating that this Witness either knows or is 
competent to establish what type of standard, - either knows or can establish 
those standards under which radiologists as opposed to orthopedic surgeons must 
practice.

 
 
Obviously, the 
cumulative characterization cannot now be sustained in face of the subsequently 
granted directed verdict on the basis of failure of proof of a violated 
standard. Consequently, the justification, if one is to be perceived, must be 
found in a generalized principle that an orthopedic surgeon is not qualified to 
testify as to radiology standards, as a 
matter of law.

 
 

5 It would not be 
totally dissimilar to consider that a jurist was not qualified to critique the 
academic analysis of his research assistant or the supervising architect to 
review the sufficiency of the contractor's work product.

 
 
            
     
Physicians who are not specially trained in diagnostic roe[n]tgenology 
may be capable of interpreting many X-ray films with reasonable accuracy, but as 
a general rule they should not rely exclusively upon their own interpretation, 
except in very simple cases or in cases coming within their own special field 
such as urology or orthopedics.

 
 
            
     1 D. 
Louisell and H. Williams, supra, at 3-86 (emphasis added). As indicated, Dr. 
Harrington was an orthopedic specialist.

 
 

6 This complex, heavily 
contested and argumentatively pursued record bespeaks to the conception of the 
trial court as accommodated by the usage of Instruction No. 18 and directed 
verdicts that judgmental mistake cannot create liability if that decision is 
either that nothing was wrong or not to do anything; so that only if something 
is done wrong can liability develop.

 
 

7 We do not understand 
the argument of appellees in brief that the foundation question was never asked 
which is confusing in consideration of what the trial court said during the in 
camera questioning of both women:

 
 
If you have more 
questions for this witness [Fairbanks] on the substance of her testimony, then 
you certainly are going to be given an opportunity to ask her those questions. 
But this Court has ruled and there will be no questions asked of this witness 
concerning the foundations for impeachment through prior alleged inconsistent 
statements made to Mrs. Perkinson.

 
 
Thereafter, the 
subject was finalized:

 
 
            
     Anything 
else, Andy [one of appellants' attorneys]? I'm just telling you how the cow ate 
the cabbage.

 
 
            
     MR. 
ANDREW HARTNETT: I understand that the cabbage has been eaten, your 
Honor.

 
 
            
     THE 
COURT: All right.

 
 
            
     MR. 
ANDREW HARTNETT: I respectfully disagree with the Court.

 
 

8 First, Annotation, 
Use of Prior Inconsistent Statements for Impeachment of Testimony of Witnesses 
Under Rule 613, Federal Rules of Evidence, 40 A.L.R. Fed. 629 (1978) and the 
later Annotation, Use or Admissibility of Prior Inconsistent Statements of 
Witness as Substantive Evidence of Facts to Which They Relate in Criminal Case - 
Modern State Cases, 30 A.L.R. 4 414 (1984). The subject has presented problems 
since not without conflict in the federal courts. To be compared are United 
States v. Garcia, 530 F.2d 650 (5th Cir. 1976) (approved and failure to give a 
limiting instruction was not plain error); United States v. Rogers, 549 F.2d 490 
(8th Cir. 1976), cert. denied 431 U.S. 918, 97 S. Ct. 2182, 53 L. Ed. 2d 229 (1977) 
(under fairness inquiry and with limiting instruction was admissible); and 
United States v. Morlang, 531 F.2d 183 (4th Cir. 1975) (inadmissable). See 
comment and included citations of text authorities, 120 F.R.D. 299 (1987), 
relating to W.R.E. 607.

 
 

9 As appellee Little 
quotes in his brief, the trial court's reasoning related:

 
 
     "THE COURT: I heard 
argument on it last night. I made a special trip to the Teton County Law Library 
and secured from that library legal materials which I then took home, along with 
the depositions of Mrs. Fairbanks And after dinner last night, I did my own 
reading on the law. I read the deposition of Mrs. Fairbanks; I studied the 
statement of the proposed testimony; came back into Court this morning; heard 
more argument on the issue. The Court doesn't feel the need for any further 
legal reference. So thank you very much, Mr. Hartnett, but I don't want 
them.

 
 
     MR. ANDREW HARTNETT: I 
take that as an order that I should not address the Court with legal 
argument?

 
 
     THE COURT: Yes, 
because it's a matter now of the law, not of the facts, and you can bring up the 
law with this or the Supreme Court at any time you want. Now, the Court has 
listened carefully to the testimony of Mrs. Perkinson. The uncontroverted - the 
uncontroverted evidence in this case will be that Mrs. Kobos called Dr. Little's 
office in late August and early September of 1981 to express her concerns about 
her child. The proffered testimony will not impeach any evidence to the 
contrary. The evidence doesn't impeach Mrs. Fairbanks, her testimony being that 
she doesn't recall. She has no recollection and that's not surprising. I 
couldn't tell you who called me last week. I know I had some telephone calls 
earlier this week but I can't tell you who called me. Thus, if it doesn't have 
the purpose or the affect of impeaching the credibility of Mrs. Fairbanks and 
thereby discrediting the weight to be given her testimony, the only testimony 
being Mrs. Kobos' testimony that I called, then, the only other purpose for the 
testimony is to prove the truth of the hearsay asserted, which hearsay would be 
otherwise inadmissible.

 
 
     Now, this proffered 
testimony does something else in this case. This proffered testimony injects 
into the case an inference, an implication, that Dr. Little's a bad man being 
surrounded by those who would commit perjury. Now, it is the judgment of this 
Court after watching Mrs. Perkinson carefully and after considering all of the 
aspects of this case that if I were a Plaintiff's lawyer in this case, I would 
like to have the Jury think that on the other side of me are a bunch of 
perjurers and people who would be surrounded by perjurers. Now, if there are 
perjurers, there are remedies for that. But the remedies are not in this 
courtroom at this time with this Judge or with this Jury. Those remedies are 
with the Teton County Prosecuting Attorney, probably a Judge other than John 
Troughton, perhaps Judge Ranck and perhaps other Defense Counsel than those that 
are seated in this courtroom and, clearly, a different 
Jury.

 
 

CARDINE, Chief 
Justice, specially concurring.

 
 

[¶46.]  I concur in the opinion of the court and, 
with respect to instruction number 18, strongly urge that this kind of 
instruction should not be given a jury. It is argument, and it is confusing. 
Thus, it is incorrect to say that physicians and surgeons are not liable for 
mere errors of judgment. They are liable for error of judgment if those errors 
result from negligence, that is "the failure to exercise the skill, diligence 
and knowledge * * * reasonably * * * exercised * * * by members of the 
profession in good standing and in the same line of 
practice."

 
 

[¶47.]  The balance of instruction number 18 
seems to say that if the acts and omissions of the defendants are an exercise of 
honest judgment, and not unreasonable, defendants are not liable. This likewise 
is misleading and a questionable statement of law. The question is not whether 
the judgment of the physician and surgeon was honest or dishonest but whether 
the physician failed to exercise the skill, diligence, and knowledge reasonably 
exercised by others. Instruction number 18 states as a matter of law that a 
physician who acts honestly and reasonably is not liable. What if he acts 
honestly and unreasonably - or acts dishonestly and reasonably? This kind of 
instruction is exceedingly confusing. More than that, the instruction as a whole 
seems to say in lay terms that a physician who acts honestly in reaching a 
judgment is not liable. That is not a correct statement of the 
law.

 
 

[¶48.]  In the vast majority of these kinds of 
cases, it is enough to define for the jury negligence and cause in simple terms, 
as stated in instruction number 10 and other instructions found in the court's 
opinion.

 
 

[¶49.]  Where a significant portion of the 
responsible medical community approves two different treatments for the same 
injury or condition, it is not negligence for a physician to choose one 
treatment over the other. For me, that does not involve an error of judgment at 
all. It is simply not negligence to choose either treatment. An example of two 
medical procedures for treating the same condition is the treatment of a 
ruptured disc. Neurologically the disc is removed without fusion. Orthopedically 
the vertebrae are fused. Both courses of treatment are common, accepted by the 
responsible medical community, and it generally is not negligence to treat a 
ruptured disc in either fashion.

 
 

[¶50.]  An error is a mistake. A mistake may or 
may not result from negligence. But what is gained by telling the jury that an 
error carefully made does not result in liability? It is argumentative. It is 
confusing. It is a clever play on words which implies to the jury that a 
physician is not liable for an error in judgment. To balance the instructions, 
if number 18 is given, the court ought to advise the jury that a mere error in 
judgment is negligence for which a physician or surgeon is liable if such error 
results from negligence. As stated, it is better that neither instruction be 
given but that the term negligence be simply defined for the 
jury.

 
 

THOMAS, Justice, 
concurring specially.

 
 

[¶51.]  I am in accord only with the result 
reached by the majority opinion. I have some views of my own with respect to the 
difficulties engendered by Instruction No. 18, and those views may accommodate 
more closely to the objection to that instruction by the plaintiffs as quoted in 
the separate opinion of Justice Brown. I perceive Instruction No. 18 as 
requiring the jury to accept the approval of the defendants' conduct by expert 
witnesses so long as that approval was honestly made and was reasonable. In his 
separate opinion, Chief Justice Cardine has pointed out some internal 
inconsistency in that instruction.

 
 

[¶52.]  Beyond its inherent departure from 
established legal rules, my perception of the instruction is that it does create 
a standard for recovery which conflicts with other instructions which were given 
by the court and are quoted in the majority opinion. Particularly, it appears to 
me to be antithetical to Instruction No. 12.

 
 

[¶53.]  Furthermore, it is not consistent with 
the general instruction, Instruction No. 1, which addresses the jury's role with 
respect to credibility of all witnesses. It is even more inconsistent with 
Instruction No. 6 relating to expert witnesses which reads as 
follows:

 
 
"A person 
is qualified to testify as an expert if he has special knowledge, skill, 
expertise, training, or education sufficient to qualify him as an expert on the 
subject to which his testimony relates. "Duly qualified experts may give their 
opinions on questions in controversy at a trial. To assist you in deciding such 
questions, you may consider the opinion with the reasons given for it, if any, 
by the expert who gives the opinion. You may also consider the qualifications 
and credibility of the expert.

 
 
"You are 
not bound to accept such an opinion as conclusive, but should give to it the 
weight to which you find it to be entitled. You may disregard any such opinion 
if you find it to be unreasonable."

 
 

[¶54.]  This court has articulated clearly the 
proposition that it is the prerogative of the trier of fact to determine what 
evidence is most dependable. E.g., State ex rel. Wyoming Worker's Compensation v. Colvin, 681 P.2d 269 
(Wyo. 1984); Cederburg v. Carter, 448 P.2d 608 
(Wyo. 1968); Cimoli v. Greyhound Corporation, 
372 P.2d 170 (Wyo. 1962). The vice in Instruction No. 18 is 
that, subject to the conditions attached, the jury is required by the 
instruction to accept the expert testimony. That is not, and should not, be the 
law. The jury is not required to accept it even if they find it to be honest and 
reasonable.

 
 

[¶55.]  In addition, this court also has assigned 
specifically to the jury the evaluation of expert witnesses, suggesting that 
their testimony need not be accepted. E.g., Oukrop v. Wasserburger, 755 P.2d 233 
(Wyo. 1988); Thomas v. Metz, 714 P.2d 1205 (Wyo. 
1986); Reed v. Hunter, 663 P.2d 513 (Wyo. 1983). An additional vice in Instruction 
No. 18 is the statement that the jury must find for the defendants based upon 
the approval of the "respectable portion of competent and reputable physicians 
or surgeons." The tenor of the instruction is antithetical to the function 
heretofore assigned to the jury by our cases.

 
 

[¶56.]  These problems with Instruction No. 18 
were exacerbated by other rulings of the district judge. His limitation on the 
use of expert witnesses by the plaintiff and the limitation of testimony by some 
of those witnesses was troublesome. The members of the jury could have concluded 
that, in addressing these matters as he did, the trial judge clearly indicated 
his position that the expert witnesses called by the plaintiff were not among 
that "respectable portion of competent and reputable physicians or surgeons." 
The demand for a "respectable portion of competent and reputable physicians or 
surgeons" also is contrary to the judge's ruling with respect to cumulative 
testimony. These matters, together with the refusal of the court to permit the 
plaintiffs to call the defendants as adverse witnesses in presenting their case 
in chief which was then followed by directed verdicts for lack of proof, all 
made painfully obvious the deprivation of a fair trial so far as the plaintiffs 
were concerned.

 
 

[¶57.]  I add that denying the plaintiffs the 
right to call the defendants as adverse witnesses in presenting their case in 
chief is not a neutral ruling. When called in the case presented by the 
defendants, counsel have a clear opportunity to tailor the testimony in chief. 
Cross-examination then can be severely limited to the scope of the direct 
examination, and it may turn out to be impossible for the plaintiffs to present 
the significant points supporting their theory. Furthermore, a substantial 
difference exists between the presentation by the plaintiffs, through questions 
permitted on cross-examination of salient points followed by an explanation, and 
the converse in which the defendants first of all present their story and 
counsel for the plaintiffs must then try to attack a prepared and planned 
presentation. In the context of weighing testimony, the latter is far less 
favorable to a plaintiff, which is why a plaintiff is permitted to call a 
defendant as an adverse witness in his case in chief.

 
 

BROWN, Justice, 
Retired, dissenting in part and concurring in part.

 
 

[¶58.]  The majority holds that giving 
Instruction Number 18 was reversible error. It states that appellants' challenge 
to instructions is the principal issue on appeal. The court was particularly 
wroth because the trial court used the terms "honest judgment" and "honestly" in 
its instruction, and states that the instruction "bespeaks in responsibility to 
moral decision and honesty."

 
 

[¶59.]  In the context of Instruction Number 18 
and the other eight malpractice instructions, it is inconceivable that the jury 
could have been misled and thought defendants' conduct would be excused as long 
as their judgment was not fraudulent or morally improper.

 
 

[¶60.]  Webster's Third New International 
Dictionary 1086 (1971), defines "honest" in part as: "candid presentation of the 
facts," "free of ostentation or pretense," "of a creditable nature." Honesty is 
defined on the same page as "adherence to the facts." In context, the words 
"honest" and "honesty" used in Instruction Number 18 could only mean adherence 
to the facts and the jury could not have rationally thought 
otherwise.

 
 

[¶61.]  Arguably, terms more precise than 
"honest" and "honestly" could have been used in the instruction. However, these 
terms are not novel. In Smith v. Beard, 56 Wyo. 
375, 110 P.2d 260, 270 (1941) (quoting Staloch v. Holm, 100 Minn. 276, 111 N.W. 264, 
267 (1907)), this court said: "`It would be * * * unreasonable to hold a 
physician responsible for an honest error 
of judgment on so uncertain problems as are presented in surgery and 
medicine.'" (Emphasis added.)

 
 

[¶62.]  Appearing on the same page of the opinion 
in Smith, the terms "honest judgment" and "honestly made" are used. Justice 
Blume certainly was not using the terms honest and honestly as opposed to the 
terms fraudulent, lying, larceny or some other moral 
deficiency.

 
 

[¶63.]  The Supreme Court of Minnesota wrote that 
at least twenty-nine other jurisdictions follow the rule that physicians are not 
liable for honest errors in judgment. In Ouellette by Ouellette v. Subak, 391 N.W.2d 810 (Minn. 1986), the court 
stated:

 
 
     "Cases of malpractice 
may be within the exception. A physician entitled to practice his profession, 
possessing the requisite qualifications, and applying his skill and judgment 
with due care, is not ordinarily liable for damages consequent upon an honest mistake or an error of 
judgment in making a diagnosis, in prescribing treatment, or in determining 
upon an operation, where there is reasonable doubt as to the nature of the 
physical conditions involved or as to what should have been done, in accordance 
with recognized authority and good current practice. * * *

 
 
* * * * * 
*

 
 
     "* * * Most 
professional men are retained or employed in order that they may give the 
benefit of their peculiar and individual judgment and skill. A lawyer, for 
example, does not contract to win a lawsuit, but to give his best opinion and 
ability. He has never been held to liability in damages for a failure to 
determine disputed questions of law in accordance with their final decision by 
courts of appeal. It would be just as unreasonable to hold a physician 
responsible for an honest error of judgment on so uncertain problems as are 
presented in surgery and medicine."

 
 
[Staloch,] 
100 Minn. at 
280-283, 111 N.W.  at 266-67.

 
 

[¶64.]  Moreover, in protecting a physician from 
liability for mere errors in judgment in choosing between alternate diagnoses or 
treatments, this court has followed a rule recognized by at least 29 other 
jurisdictions. See also W. Keeton, D. Dobbs, R. Keeton and P. Owen, Prosser 
& Keeton on the Law of Torts 186 (5th Ed. 1984).

 
 

Id. at 814 
(emphasis added and footnote omitted).

 
 

[¶65.]  In Watson v. Hockett, 107 Wn.2d 158, 727 P.2d 669, 673 (1986), the court stated:

 
 
     The "error of 
judgment" instruction unanimously upheld by this court in Miller, and also 
proposed by Dr. Hockett in this case, is also proper:

 
 
     "A physician or 
surgeon is not liable for an honest 
error of judgment if, in arriving at that judgment, the physician or surgeon 
exercised reasonable care and skill, within the standard of care he was obliged 
to follow."

 
 
(Italics 
ours.) Miller, 91 Wn.2d  at 160 n. 4, 588 P.2d 734. Henceforth, however, the 
italicized word "honest" should not be used in those cases where it is 
appropriate to give this instruction. This is because the use of the word 
"honest" imparts an argumentative aspect into the instruction which, as 
discussed above, does not coincide with current jury instruction 
practice.

 
 
See also 
Perkins v. Walker, 406 N.W.2d 189 (Iowa 1987); Miller v. 
Kennedy, 91 Wn.2d 155, 588 P.2d 734 (1978) ("honest" error of judgment 
instruction upheld). In 61 Am.Jur.2d, Physicians & Surgeons, § 209 (1981), 
the term "honest error" is used in discussing professional 
judgment.

 
 

[¶66.]  "No party may assign as error the giving 
or the failure to give an instruction unless he objects thereto before the jury 
retires to consider its verdict, stating 
distinctly the matter to which he objects and the grounds of his objection." 
W.R.C.P. 51 (emphasis added). At the instruction conference, counsel for 
appellants objected to giving Instruction Number 18, 
stating:

 
 
In the 
first instance, your Honor, I think that Vassos v. Roussalis, where it defines 
what negligence is, - I mean, what standard of care is, impliedly overrules any 
case that would additionally instruct on the issue of error of judgments on the 
first instance. Probably the vast majority of any case in the exercise of 
medicine requires judgment. The question - and that evidence comes into the 
trial. It's up to the Jury to determine if, from the facts of the case, that's 
excused by knowledge, skill and diligence in the evidence. To instruct about 
judgment, particularly, calls the attention to the Jury of one of many issues 
that they've heard in the evidence and in certain circumstances, could - could 
be tantamount to issuing a directed verdict in our 
judgment.

 
 
     Two, I don't think 
anything in Conway v. Wright suggests that the language of 
the decision should be given as an instruction. And I think that, clearly, this 
sets up a situation where a professional judgment being exercised, in almost any 
case, requires the Plaintiffs to almost prove, you know, beyond a reasonable 
doubt or prove some kind of burden far greater than the law requires. The 
instruction, in my judgment, simply, - you know, it's unnecessary to give and it 
does tend to direct a verdict against because, you know, all I have to say is 
while this was a judgmental issue, that's for the Jury to 
decide.

 
 

[¶67.]  It is most difficult to determine 
precisely what appellants are complaining about. At the instruction conference, 
they talk about the instruction imposing on them a burden of proof "beyond a 
reasonable doubt" and a tendency to "direct a verdict against them." It is noted 
in appellants' objection that they do not complain about the use of the terms 
"honest judgment" and "honestly." This latent concern about these terms 
apparently developed on appeal.

 
 

[¶68.]  W.R.C.P. 51 is designed to assist the 
trial court to correct potential errors in the instructions. The purpose of the 
rule is defeated if alleged errors are asserted for the first time on appeal. 
Perhaps if appellant had properly objected, the court would have deleted the 
terms "honest" and "honestly" or substituted acceptable terms. Appellants' 
objection to Instruction Number 18 does not minimally comply with Rule 51, and 
they should not now be heard to complain.

 
 

[¶69.]  In its opinion, the majority addresses 
other issues raised by appellants, and is critical of many of the trial court's 
rulings and determinations. However, the majority's reversal is not based on 
those additional issues. Those issues are discretionary matters with the trial 
court. I see no abuse of discretion and would therefore affirm the trial court 
in its determinations.

 
 

[¶70.]  With respect to granting a directed 
verdict in favor of Charles Everts, M.D., the radiologist, I concur only in the 
result determined by the majority. I agree with the trial court that there was 
not competent evidence of any direct, proximate cause between the conduct and 
actions of Dr. Everts and the injuries appellants contend occurred. The trial 
court, however, improperly granted the directed verdict without allowing 
appellants to call Dr. Everts as an adverse witness in their case in chief. Had 
Dr. Everts testified as an adverse witness, it is highly unlikely that he would 
have made appellants' case, but appellants had a right to try to cure the 
deficiencies in their proofs through the testimony of appellee 
Everts.

 
 

[¶71.]  I would reverse the trial court in 
granting a summary judgment to Dr. Everts and affirm in all other 
respects.