Title: Beard v. Meridia Huron Hosp.

State: ohio

Issuer: Ohio Supreme Court

Document:

[Cite as Beard v. Meridia Huron Hosp., 106 Ohio St.3d 237, 2005-Ohio-4787.] 
 
 
BEARD, ADMR., APPELLEE, v. MERIDIA HURON HOSPITAL ET AL.;  
NICHOLSON, APPELLANT. 
[Cite as Beard v. Meridia Huron Hosp., 106 Ohio St.3d 237, 2005-Ohio-4787.] 
Expert witnesses are permitted to testify that their opinions are based, in part, on 
their review of professional literature, so long as the literature is not 
identified, quoted, or introduced into evidence. 
(No. 2004-0048 — Submitted February 1, 2005 — Decided September 28, 2005.) 
APPEAL from the Court of Appeals for Cuyahoga County, 
No. 82541, 2003-Ohio-5929. 
__________________ 
SYLLABUS OF THE COURT 
Expert witnesses are permitted to testify that their opinions are based, in part, on 
their review of professional literature. 
__________________ 
MOYER, C.J. 
{¶ 1} The issue presented in this case concerns the extent to which an 
expert witness, testifying on direct examination, may make reference to 
professional literature, which is often referred to as “learned treatises.”  We hold 
that an expert witness may testify that his or her opinions are based, in part, on a 
review of professional literature.  Applying this holding to the facts of the instant 
case, we reverse the judgment of the court of appeals and reinstate the order of the 
trial court. 
I 
{¶ 2} Defendant-appellant, Dr. Oscar Nicholson Jr., performed an 
elective hernia-repair operation on Ralph Moss.  Moss died one week after the 
operation, and plaintiff-appellee, Charlene Beard, the administrator of his estate, 
SUPREME COURT OF OHIO 
2 
brought a medical-malpractice action against appellant.  Appellee alleged, among 
other things, that appellant should not have performed the operation, given that 
Moss’s white-blood-cell count on the day before the operation was 2,300, while 
the reference range for a normal count is 4,500 to 11,000.  Appellee asserts that 
Moss’s low white-blood-cell count prevented him from being able to resist 
infection and, ultimately, led to his death. 
{¶ 3} At trial, Dr. Richard Schlanger provided expert testimony on 
behalf of appellee, and Doctors Franklin Price and Andrew Pietzman testified as 
expert witnesses for appellant.  Appellant also testified as an expert witness in his 
defense.  He stated that his decision to operate on Moss was reasonable because 
Moss had benign familial neutropenia, a condition characterized by chronically 
low white-blood-cell counts.  According to appellant, patients with benign 
familial neutropenia do not have a lowered ability to fight infection, despite their 
lower blood-cell counts.  Appellant then testified as follows regarding the 
standard of care for operating on a patient with this condition. 
{¶ 4} “Q.  Now, what is the standard of care of a surgeon like yourself 
regarding what you need in terms of a white blood cell count to safely take a 
patient with benign familial neutropenia to surgery?  
{¶ 5} “A.  Patients who have benign familial neutropenia, if they have a 
complete white blood cell count and complete count meaning neutrophils, 
basophils, eosinophils and lymphocytes greater than one thousand, one thousand 
and above.  And, this is something that’s documented in the medical and surgical 
literature.” 
{¶ 6} Appellee objected to appellant’s testimony, arguing that 
appellant’s reference to the medical and surgical literature should be struck as 
inadmissible hearsay.  The trial judge overruled the objection. 
{¶ 7} Appellant then testified as follows that he met the standard of care 
in taking Moss to surgery with a white-blood-cell count of 2,300. 
January Term, 2005 
3 
{¶ 8} “Q.  Doctor, I’ll ask my question again.  Do you have an opinion 
as to a reasonable degree of medical probability that you met the accepted 
standard of care in taking Mr. Moss to surgery, with a white blood cell count of 
2,300 and no differential, on December 12th, 2000? 
{¶ 9} “A.  Yes. 
{¶ 10} “Q.  What is that opinion? 
{¶ 11} “A.  That opinion is that I met the standard of care to take Mr. 
Moss to surgery. 
{¶ 12} “Q.  What is the basis of that opinion, Doctor? 
{¶ 13} “A.  That opinion is based on the fact that the medical and surgical 
literature states that patients who have benign familial neutropenia can be 
operated on safely with white blood cell counts greater than a thousand.” 
{¶ 14} Counsel for appellee again objected, arguing that appellant’s 
second reference to the literature also constituted inadmissible hearsay.  The trial 
court overruled this objection and appellant continued to address the bases for his 
opinion. 
{¶ 15} “Q.  Doctor, you made reference to the literature in your response.  
What literature are you referring to? 
{¶ 16} “A.  There are various review articles in the medical as well as 
surgical literature that deals [sic] with the benign, the condition of benign familial 
neutropenia. 
{¶ 17} “Q.  Is your opinion based also on your education and your 
training and your experience over the years?  
{¶ 18} “A.  Yes, it is.” 
{¶ 19} The jury returned a verdict in favor of appellant, and the trial court 
entered judgment consistent with the jury verdict.  On appeal, the Eighth District 
Court of Appeals reversed the judgment and remanded the cause for a new trial, 
SUPREME COURT OF OHIO 
4 
holding that the trial court had committed prejudicial error by admitting 
appellant’s references to professional literature. 
II 
{¶ 20} Decisions regarding the admissibility of evidence are within the 
broad discretion of the trial court.  State v. Hymore (1967), 9 Ohio St.2d 122, 128, 
38 O.O.2d 298, 224 N.E.2d 126.  A decision to admit or exclude evidence will be 
upheld absent an abuse of discretion.  O'Brien v. Angley (1980), 63 Ohio St.2d 
159, 164-165, 17 O.O.3d 98, 407 N.E.2d 490.  Even in the event of an abuse of 
discretion, a judgment will not be disturbed unless the abuse affected the 
substantial rights of the adverse party or is inconsistent with substantial justice.  
Id. 
{¶ 21} Thus, we must first determine whether the trial court abused its 
discretion by admitting appellant’s testimony.  If we determine that the trial court 
abused its discretion, we must then determine whether appellee’s substantial 
rights were undermined by admission of the testimony. 
A. Abuse of Discretion 
{¶ 22} “ ‘The term “abuse of discretion” connotes more than an error of 
law or judgment; it implies that the court’s attitude is unreasonable, arbitrary or 
unconscionable.’ ” Blakemore v. Blakemore (1983), 5 Ohio St.3d 217, 219, 5 
OBR 481, 450 N.E.2d 1140, quoting State v. Adams (1980), 62 Ohio St.2d 151, 
157, 16 O.O.3d 169, 404 N.E.2d 144.  We conclude that the trial court did not 
abuse its discretion in allowing appellant’s testimony, because his references to 
the professional literature did not constitute inadmissible hearsay. 
{¶ 23} Hearsay is defined in Evid.R. 801(C) as “a statement, other than 
one made by the declarant while testifying at the trial or hearing, offered in 
evidence to prove the truth of the matter asserted.”  Statements that fall within this 
definition are not admissible unless an exception is made by the United States or 
Ohio Constitution, by Ohio statute, or by rules prescribed by this court.  Evid.R. 
January Term, 2005 
5 
802.  Because works of professional literature contain statements that if 
introduced as evidence would fall within the definition of hearsay, and because 
the Ohio Rules of Evidence, unlike the Federal Rules of Evidence, do not contain 
a learned-treatise exception to the hearsay rule, such works “are inadmissible as 
independent evidence of the theories and opinions therein expressed.”1 Piotrowski 
v. Corey Hosp. (1961), 172 Ohio St. 61, 69, 15 O.O.2d 126, 173 N.E.2d 355.  In 
Piotrowski, we noted that the reasons for exclusion include the inability to verify 
the validity of the opinions and conclusions within the works and the lack of 
opportunity to cross-examine the authors of those opinions and conclusions.  Id.  
If, during direct examination, a witness were permitted to offer statements from 
professional literature to prove the truth of the matter asserted in those statements, 
the witness would be acting as a conduit for the out-of-court statements of the 
authors of those literary works. 
{¶ 24} There is a difference between a witness’s referring to specific 
statements in professional literature as substantive evidence and an expert 
witness’s referring to the literature as being part of the basis for that expert’s 
opinion.  While the former reference would be inadmissible hearsay, numerous 
courts in Ohio have held2 that the latter reference is admissible.  We agree with 
the decisions in those cases. 
{¶ 25} Our decision is consistent with the Ohio Rules of Evidence.  
Evid.R. 702(B) provides that a “witness is qualified as an expert by specialized 
knowledge, skill, experience, training, or education regarding the subject matter 
                                                          
 
1.  In Ohio, learned treatises may be used for impeachment purposes.  Evid.R. 706.  Evid.R. 706 
provides that learned treatises may be used to show that an expert is unaware of their existence or 
unfamiliar with their contents.  See, also, Stinson v. England (1994), 69 Ohio St.3d 451, 458, 633 
N.E.2d 532.  Additionally, the contents of a treatise may be used to impeach the credibility of a 
witness who relied on the treatise in forming his or her opinion or who acknowledges the 
authoritative nature of the treatise.  Id.  
 
2.  See, e.g., Compher v. Kroger Co., 5th Dist. No. 04 CA 12, 2005-Ohio-482, ¶ 47-80; State v. 
Echols (1998), 128 Ohio App.3d 677, 698, 716 N.E.2d 728; Hart v. Lechnar (June 7, 1991), 6th 
Dist. No. L-89-276.   
SUPREME COURT OF OHIO 
6 
of the testimony.”  Pursuant to this rule, a witness becomes qualified to testify as 
an expert by virtue of the fact that he or she has been exposed to and has absorbed 
information from sources that may not be admissible under the Rules of Evidence.  
Evid.R. 703 states that an expert witness may base his or her opinion on facts or 
data “perceived by him or admitted in evidence at the hearing.”  However, we 
have acknowledged that information that would not be admissible at trial may 
serve as a basis for an expert’s background knowledge without violating Evid.R. 
703.  See State v. Mack (1995), 73 Ohio St.3d 502, 512, 653 N.E.2d 329.  
Moreover, Evid.R. 706, the rule that permits impeachment with statements from 
learned treatises, is based on the premise that experts are likely to rely on 
professional literature in forming their opinions.  Cf. Stinson v. England (1994), 
69 Ohio St.3d 451, 633 N.E.2d 532, paragraph two of the syllabus (holding that 
“the substance of [a] treatise may be employed only to impeach the credibility of 
an expert witness who has relied upon the treatise * * * or has acknowledged its 
authoritative nature”). 
{¶ 26} Experts have been permitted to testify regarding the information 
that provides the basis for their opinions.  See State v. Echols (1998), 128 Ohio 
App.3d 677, 698, 716 N.E.2d 728.  Because experts are permitted to base their 
opinions on their education, including their review of professional literature, 
training, and experience, it follows that experts are also permitted to testify 
regarding that information. Accordingly, we hold that expert witnesses are 
permitted to testify that their opinions are based, in part, on their review of 
professional literature. 
{¶ 27} In the case at bar, appellant made two references to the 
professional literature after describing benign familial neutropenia and stating his 
opinion with regard to the standard of care for operating on a patient with that 
condition. 
January Term, 2005 
7 
{¶ 28} First, appellant confirmed that his opinion regarding the standard 
of care was consistent with findings “documented in the medical and surgical 
literature.”   Appellant did not offer a statement from the professional literature 
for its truth; indeed, appellant did not offer any statement from the literature for 
any purpose.  Rather, by adding that his opinion regarding the standard of care 
was consistent with findings “documented in the medical and surgical literature,” 
appellant merely confirmed that the detailed expert opinion he had just 
communicated to the jury was supported by the professional literature. 
{¶ 29} When an expert testifies that his or her opinion is based in part on 
professional literature, the expert is essentially saying that the literature supports 
his or her opinion.  Thus, appellant’s first reference to the professional literature is 
consistent with the Ohio Rules of Evidence and does not violate the prohibition 
on learned treatises. 
{¶ 30} Appellant subsequently testified that, in his expert opinion, he had 
met the standard of care in taking Moss to surgery with a white-blood-cell count 
of 2,300.  His counsel asked him to explain the basis for his opinion, and 
appellant replied:   
{¶ 31} “A.  That opinion is based on the fact that the medical and surgical 
literature states that patients who have benign familial neutropenia can be 
operated on safely with white blood cell counts greater than a thousand.” 
{¶ 32} This second reference is more problematic than the first because by 
answering “the * * * literature states that * * *,” appellant was apparently offering 
a statement from the literature.  However, appellant did not offer precise 
statements from the literature so that they might be considered independently to 
prove compliance with the standard of care in Moss’s case.  Instead, he merely 
referred to statements in the medical and surgical literature while explaining the 
basis for his previously articulated opinion that he had met the standard of care in 
Moss’s case.  Moreover, he clarified that he was referring, generally, to 
SUPREME COURT OF OHIO 
8 
statements from “various review articles in the medical as well as surgical 
literature,” that the literature provided only a partial basis for his opinion, and that 
his opinion was also based on his education, training, and experience.  Pursuant to 
the Ohio Rules of Evidence, appellant is permitted to testify in this manner. 
{¶ 33} We also note that the reasons for excluding treatise information 
expressed in Piotrowski, 172 Ohio St. 61, 15 O.O.2d 126, 173 N.E.2d 355, are not 
applicable here.  Appellant did not act as a conduit for the out-of-court statements 
of others.  Rather, he gleaned information from various sources, including 
medical and surgical literature, and used that information to reach his own opinion 
as to the applicable standard of care.  He then testified under oath with regard to 
his opinion and was available for cross-examination regarding that opinion.  
Opposing counsel was free to use cross-examination to challenge appellant’s 
reasoning, to verify the validity of his conclusions, and to attack the basis for his 
opinion. 
{¶ 34} For these reasons, we hold that the trial court acted within its 
discretion in allowing appellant’s testimony. 
B. Substantial Justice 
{¶ 35} Even if we assume that the trial court abused its discretion in 
admitting appellant’s testimony, reversal would not be warranted in this case.  An 
improper evidentiary ruling constitutes reversible error only when the error affects 
the substantial rights of the adverse party or the ruling is inconsistent with 
substantial justice.  O'Brien, 63 Ohio St.2d at 164-165, 17 O.O.3d 98, 407 N.E.2d 
490.  “ ‘Generally, in order to find that substantial justice has been done to [a 
party] so as to prevent reversal of a judgment for errors occurring at the trial, the 
reviewing court must not only weigh the prejudicial effect of those errors but also 
determine that, if those errors had not occurred, the jury or other trier of the facts 
would probably have made the same decision.’ ”  Id., quoting Hallworth v. 
Republic Steel Corp. (1950), 153 Ohio St. 349, 41 O.O. 341, 91 N.E.2d 690, 
January Term, 2005 
9 
paragraph three of the syllabus.  We conclude that the trial court’s admission of 
appellant’s testimony did not prejudice appellee’s substantial rights. 
{¶ 36} Appellant’s general references to the literature confirmed and 
provided support for his previously stated opinion regarding the standard of care 
for performing surgery on a person with benign familial neutropenia.  Therefore, 
the jury would have heard his expert opinion regarding these matters even if the 
trial court had stricken his references to the literature. 
{¶ 37} Two other experts — Drs. Price and Pietzman — provided 
testimony that supported appellant’s contention that he met the standard of care 
under these circumstances.  Dr. Price, Moss’s treating oncologist, explained 
benign familial neutropenia and the fact that persons with this condition do not 
experience a lowered ability to fight infection, despite their lower-than-normal 
white-blood-cell counts.  He also agreed with appellant that Moss’s chronically 
low white-blood-cell count was consistent with benign familial neutropenia. 
{¶ 38} Dr. Pietzman further corroborated appellant’s contention that he 
had met the standard of care in operating on Moss.  Dr. Pietzman testified that 
appellant’s decision to operate was reasonable, given that Moss “had a chronically 
low white count and this was not a new or an acute process.”  He further stated 
that Moss’s low white-blood-cell count was not a proximate cause of his death. 
{¶ 39} Finally, the testimony proffered by appellee’s expert, Dr. 
Schlanger, did not directly contradict appellant’s alleged hearsay statements.  Dr. 
Schlanger testified as follows:  
{¶ 40} “Q: Okay.  Doctor, do you have an opinion as to what the standard 
of care in Ohio demands of a surgeon with respect to a preoperative evaluation for 
a patient who has recently undergone chemotherapy?  
{¶ 41} “A: I do have an opinion. 
{¶ 42} “Q: And what is your opinion?  
SUPREME COURT OF OHIO 
10 
{¶ 43} “A: My opinion is that a patient that undergoes chemotherapy, that 
has just finished chemotherapy, needs to have the blood work looked at extremely 
carefully.  And the fact that if the blood count is lower than acceptable standard, 
which in this case at 2.3 [x 103], the patient either should have been sent back to 
the oncologist for possible either GSF or Lithium, which would have raised their 
white blood cell count to a safe level to proceed with surgery.  I also would have 
looked at nutritional parameters to make sure that if the patient has an operation, 
they will heal.  And neither of these things were done.” 
{¶ 44} Dr. Schlanger did not discuss benign familial neutropenia or the 
minimum white-blood-cell count that is required in order to operate on a person 
with that condition.  Rather, he identified two methods for raising white-blood-
cell counts and said that one of those methods should have been used to boost 
Moss’s white-blood-cell count.  He further stated that appellant ought to have 
evaluated Moss’s ability to heal before taking Moss to surgery with a blood-cell 
count of 2,300.  In fact, at oral argument in this appeal, appellee conceded that her 
expert did not contest appellant’s contention that a person with benign familial 
neutropenia can safely be operated on when he or she has a white-blood-cell 
count over 1,000. 
{¶ 45} For the foregoing reasons, we conclude that the court of appeals 
erred when it reversed the judgment for appellant.  The judgment of the court of 
appeals is reversed, and the order of the trial court is reinstated. 
Judgment reversed. 
 
LUNDBERG STRATTON, O’CONNOR, O’DONNELL and LANZINGER, JJ., 
concur. 
 
RESNICK and PFEIFER, JJ., dissent. 
__________________ 
 
 
January Term, 2005 
11 
 
ALICE ROBIE RESNICK, J., dissenting. 
{¶ 46} The court of appeals fully appreciated the nuances of the issue 
presented, applied the relevant precedents precisely as they should have been 
applied, and unanimously reached the right result, which was to reverse the jury 
verdict for appellant, Dr. Oscar Nicholson Jr., and to remand for a new trial.  The 
majority loses focus on the true issue, misperceives the prejudicial nature of the 
testimony at issue, and reverses a well-reasoned judgment, thereby reinstating a 
flawed jury verdict.  I dissent. 
{¶ 47} In Piotrowski v. Corey Hosp. (1961), 172 Ohio St. 61, 15 O.O.2d 
126, 173 N.E.2d 355, this court held at the syllabus: 
{¶ 48} “Generally, it is prejudicial error to admit in evidence, over 
objection, medical articles or treatises as independent evidence of the theories and 
opinions therein expressed, and this is particularly true where the evidence in the 
case is conflicting and of such a character that a verdict for either party would be 
supportable.” 
{¶ 49} While paying lip service to Piotrowski and the Ohio Rules of 
Evidence as they apply to expert testimony and learned treatises, the majority 
strays from the fundamental principles that should guide our inquiry.  It was the 
inherently prejudicial nature of the “independent evidence of the theories and 
opinions therein expressed” of the medical literature that concerned the court in 
Piotrowski.  The court of appeals understood that a proper application of the 
reasoning underlying the result in Piotrowski compels a new trial in this case. 
{¶ 50} Several times during his testimony, Dr. Nicholson referred to 
unspecified medical literature sources as supporting his opinion that he had met 
the standard of care.  After Dr. Nicholson had testified for a second time that 
unnamed “medical and surgical literature” states a standard of care allowing 
patients with benign familial neutropenia to be operated on when their white-
blood-cell counts are greater than 1,000, appellee’s attorney approached the bench 
SUPREME COURT OF OHIO 
12 
and renewed an earlier objection, stating, “We would ask that the response to the 
question be stricken on the basis that his answer was that based upon the literature 
that he’s read.  Well, I can’t, how can I cross-examine him when I don’t know 
what he’s read.  And, it’s a clear hearsay response.  It’s got to go out.” 
{¶ 51} The trial court refused a second time to strike Dr. Nicholson’s 
references to medical literature.  The trial court even appears to have invited a 
response from Dr. Nicholson that would have allowed him to improperly name 
specific literature, stating in response to the objection, “Overruled.  Ask him what 
he read.”  Dr. Nicholson’s attorney then requested Dr. Nicholson to specify the 
medical literature he was referring to.  Although Dr. Nicholson did not name any 
specific piece of literature as his source, he testified, “There are various review 
articles in the medical as well as surgical literature that deals with the benign, the 
condition of benign familial neutropenia.” 
{¶ 52} Dr. Nicholson’s attorney then led his client to add a qualifier to the 
mention of the unnamed literature as the sole source of Dr. Nicholson’s opinion, 
asking in what appears to be an afterthought, “Is your opinion based also on your 
education and your training and your experience over the years?”  Dr. Nicholson 
replied, “Yes, it is.” 
{¶ 53} I fully agree with the court of appeals’ cogent analysis of why Dr. 
Nicholson’s testimony was improper.  The court of appeals acknowledged that 
“[w]hile learned treatises may not be admitted as evidence or relied on for the 
truth of the opinions stated therein, experts have been permitted to refer to 
literature generally as forming part of the basis for their opinion.  See Gartner v. 
Hemmer, Hamilton App. No. C-010216, 2002-Ohio-2040 [2002 WL 727014]; 
Limle v. Laboratory Corp. of Am. (2000), 137 Ohio App.3d 434, 438-439 [738 
N.E.2d 890].  We recognize that no one becomes an expert without research, 
education, training, and experience and that an expert is entitled to rely on this 
background in forming his opinion.  However, there is a distinction between 
January Term, 2005 
13 
reference to literature as being part of the collective basis for an expert’s opinion 
and reference to literature as substantive evidence.” 
{¶ 54} The court of appeals went on to elaborate precisely why Dr. 
Nicholson’s testimony should not have been allowed: 
{¶ 55} “In this case, Dr. Nicholson testified that the white blood cell count 
level to safely take a patient with benign familial neutropenia to surgery was 
greater than 1,000.  He unequivocally stated that this is something that is 
documented in the medical and surgical literature.  Dr. Nicholson also testified 
that the standard of care in taking Mr. Moss to surgery with a white blood cell 
count of 2,300 was met, based upon the fact that the medical and surgical 
literature states that patients who have benign familial neutropenia can be 
operated on safely with white blood cell counts greater than 1,000. 
{¶ 56} “Dr. Nicholson’s reference to the medical literature was used for 
the truth of the matter contained therein, not as a general basis for his opinion.  
Therefore, his testimony was hearsay and was used as substantive evidence.  See 
Pool v. Wade (1996), 115 Ohio App.3d 449 [685 N.E.2d 791]; Edwards v. 
Radecki (May 14, 1993), Lucas App. No. L-92-042 [1993 WL 155632].  While 
Dr. Nicholson later stated his opinion was also based on his training, education, 
and experience, this does not change the fact that his earlier reference to the 
medical literature amounted to hearsay. 
{¶ 57} “Moreover, Dr. Nicholson’s testimony was not a generalized 
statement that incorporated medical literature with his education, training, and 
experience to form his opinion.  Rather, Dr. Nicholson specifically stated [that] 
the fact that it is safe to operate on patients with benign familial neutropenia with 
white blood cell counts greater than 1,000 is documented in medical literature.  In 
essence, Dr. Nicholson was relying on a phantom expert to support his opinion.  
While Dr. Nicholson may also have believed that he met the standard of care 
based on his education, training, and experience, his specific reference to medical 
SUPREME COURT OF OHIO 
14 
literature to establish the level at which the standard was met was an improper use 
of the literature as substantive evidence. 
{¶ 58} “We find that the trial court erred in allowing Dr. Nicholson’s 
testimony on this matter as it was inadmissible hearsay.” 
{¶ 59} The court of appeals additionally correctly determined that the trial 
court’s refusal to prevent Dr. Nicholson from testifying as he did about the 
medical literature was prejudicial to appellee:  “Dr. Nicholson was permitted to 
rely on the literature as substantive evidence to support his opinion that Moss’s 
white blood cell count was at a safe level to perform surgery.  Further, it cannot 
be said that but for the error in allowing this testimony, the trier of fact would 
probably have made the same decision.  Accordingly, we find that the trial court’s 
action was inconsistent with substantial justice.” 
{¶ 60} I agree with the conclusion of the court of appeals that appellee 
was significantly prejudiced by Dr. Nicholson’s improper references to 
unidentified “phantom” medical literature to support his alleged compliance with 
the applicable standard of care and that a new trial is warranted.  This trial 
centered on whether Dr. Nicholson did, in fact, comply with that standard.  The 
unspecified medical literature was used as substantive factual evidence of the 
standard of care, but was totally imprecise as to its origin and totally unambiguous 
as to the substance of its assertion.  Appellee had no way to effectively cross-
examine Dr. Nicholson to counter the effect of the references, and the jury’s 
verdict was influenced by crucial testimony it should never have heard.  I would 
affirm the judgment of the court of appeals. 
 
PFEIFER, J., concurs in the foregoing dissenting opinion. 
__________________ 
 
Novak, Robenalt, Pavlik & Scharf, L.L.P., William J. Novak, Thomas D. 
Robenalt, and Colin P. Sammon, for appellee. 
January Term, 2005 
15 
Moscarino & Treu, L.L.P., Kris H. Treu, Edward S. Jerse, and Michael M. 
Matile, for appellant. 
______________________