Title: REICHERT v. PHIPPS

State: wyoming

Issuer: Wyoming Supreme Court

Document:

REICHERT v. PHIPPS2004 WY 784 P.3d 353Case Number: 02-159Decided: 02/11/2004
OCTOBER 
TERM, A.D. 2003

 

                                                                                                                                   

 

DELORES 
J. REICHERT,

 

Petitioner,

 

v.

 

JAMES 
A. PHIPPS and

GARY 
L. LANPHIER,

 

Respondents.

 

 

Representing 
Petitioner:

 

            
Richard 
Wolf of Wolf & Tiedeken, LC, Cheyenne, Wyoming; and Jerry M. Smith of Sigler 
& Smith, Torrington, Wyoming.

 

Representing 
Respondents:

 

            
John 
A. Sundahl and Brian J. Hanify of Sundahl, Power, Kapp & Martin, Cheyenne, 
Wyoming; and J. Kent Rutledge and Kevin C. Cook of Lathrop & Rutledge, P.C., 
Cheyenne, Wyoming.

 

Before 
HILL, C.J., and GOLDEN, LEHMAN, KITE, and VOIGT, JJ.

 

VOIGT, 
Justice, delivered the opinion of the Court; 
LEHMAN, 
Justice, filed a dissenting opinion.

 

 

            
VOIGT, Justice.

 

[¶1]      The petitioner, 
in a civil negligence action, has asked this Court to review the trial court's 
order prohibiting her from offering evidence at trial that the automobile 
collision at issue caused the fibromyalgia from which she suffers.  Finding an abuse of discretion, we 
reverse.

 

 

[¶2]      Did the trial 
court abuse its discretion in excluding expert testimony that the automobile 
collision caused, contributed to, or triggered 
fibromyalgia?

 

 

[¶3]      On August 26, 
1996, the petitioner, Delores J. Reichert, was injured in an automobile accident 
that she claims was caused by the respondents, James Phipps and Gary 
Lanphier.  She has filed a civil 
action in the district court in Goshen County, wherein she seeks recovery from 
the respondents for her injuries.  
The petitioner has designated two of her treating physicians, Robin R. 
Ockey, M.D., and Robert Monger, M.D., to testify that she suffers from 
fibromyalgia (FM) and that the FM was caused by the automobile accident.  FM is a chronic musculoskeletal pain 
syndrome more fully described as follows:

 

FM 
is a syndrome of widespread pain, decreased pain threshold, and characteristic 
symptoms, including non-restorative sleep, fatigue, stiffness, mood disturbance, 
irritable bowel syndrome, headache, paresthesias, and other less common 
features.  Widespread pain has 
generally been defined by the number of body regions involved . . . or by a 
pattern of pain complaint that involves both sides of the body, upper and lower 
body, and axial skeleton.  Decreased 
pain threshold (tenderness) is indicated by the proportion of specific sites 
that elicit complaints of pain on palpation.

 

Frederick 
Wolfe, The Fibromyalgia Syndrome:  
A Consensus Report on Fibromyalgia and Disability, 23 Journal of 
Rheumatology 534, 534 (1996) (footnotes 
omitted).

 

[¶4]      In response to 
the petitioner's designation of expert witnesses, the respondents filed a Motion 
in Limine to Exclude Fibromyalgia Causation Claims and Motion for Determination 
Under Rule 56(d) of the Wyoming Rules of Civil Procedure.1  The respondents do not contend that FM 
is not a recognized syndrome nor do they suggest that the petitioner does not 
suffer from FM.  Rather, their 
position is that there is insufficient scientific knowledge to support the 
theory that FM can be caused by physical trauma.  The trial court agreed with the 
respondents and granted their motion.  
In August 2002, we granted the petitioner's Petition for Writ of Review 
as to that question.

 

 

[¶5]      Trial court 
rulings on the admissibility of evidence are reviewed for an abuse of 
discretion.  Clark v. Gale, 
966 P.2d 431, 435 (Wyo. 1998).  The ultimate issue is whether the trial 
court reasonably could have concluded as it did or whether it exceeded the 
bounds of reason under the circumstances.  
Id. (quoting Hilterbrand v. State, 930 P.2d 1248, 1250 (Wyo. 1997)).  This standard 
applies to a trial court's exclusion of expert testimony.  Chapman v. State, 2001 WY 25, ¶ 
8, 18 P.3d 1164, 1169 (Wyo. 2001); 
Bunting v. Jamieson, 984 P.2d 467, 470 (Wyo. 1999).

 

[¶6]      Expert testimony 
is admissible if it meets the requirements of W.R.E. 702:

 

            
If scientific, technical, or other specialized knowledge will assist the 
trier of fact to understand the evidence or to determine a fact in issue, a 
witness qualified as an expert by knowledge, skill, experience, training, or 
education, may testify thereto in the form of an opinion or 
otherwise.

 

[¶7]      The United States 
Supreme Court has described a "gatekeeper" function for the trial court under 
Rule 702, whereby the reliability of proferred expert testimony is tested.  Kumho Tire Co., Ltd. v. Carmichael, 
526 U.S. 137, 141, 119 S. Ct. 1167, 143 L. Ed. 2d 238 (1999); 
Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 592-93, 113 S. Ct. 2786, 125 L. Ed. 2d 469 (1993), cert. denied, 516 U.S. 869 
(1995).  In Bunting, we adopted the 
Daubert analysis and made clear that it applies to the "opinions of a 
treating physician based on medical knowledge within the physician's specific 
area of expertise."  Bunting, 
984 P.2d  at 471.

 

The 
primary goal of Daubert's gatekeeping requirement "is to ensure the 
reliability and relevancy of expert testimony.  It is to make certain that an expert, 
whether basing testimony upon professional studies or personal experience, 
employs in the courtroom the same level of intellectual rigor that characterizes 
the practice of an expert in the relevant field."

 

Id. 
(quoting Black v. Food Lion, Inc., 171 F.3d 308, 311 (5th Cir. 
1999)).

 

[¶8]      In 
Bunting, we adopted Daubert's two-part test:  first, the trial court is to determine 
whether the methodology or technique used by the expert is reliable, and second, 
the trial court must determine whether the proposed testimony "fits" the 
particular case.  Bunting, 
984 P.2d  at 471.  We also noted with approval the 
non-exclusive criteria that have been utilized to guide trial courts in making 
that first determination:

 

1) 
whether the theory or technique in question can be and has been tested; 2) 
whether it has been subjected to peer review and publication; 3) its known or 
potential rate of error along with the existence and maintenance of standards 
controlling the technique's operation; . . . 4) the degree of acceptance within 
the relevant scientific community[;] . . . [5)] the extensive experience and 
specialized expertise of the expert[;] . . . [6)] whether the expert is 
proposing to testify about matters growing naturally and directly out of 
research [he has] conducted independent of the litigation; and [7)] the 
non-judicial uses to which the method has been put[.]

 

Id. 
at 472. As to the second part of Daubert's two-part testwhether the 
expert testimony "fits" the particular facts of the casewe concluded in 
Bunting that this is a question of relevance that incorporates the 
concept of "helpfulness" found in W.R.E. 702.  In other words, "the expert's opinion 
must relate to an issue that is actually in dispute and must provide "a valid 
scientific connection to the pertinent inquiry."'"  Bunting, 984 P.2d at 
472 (quoting Graham v. Playtex 
Products, Inc., 993 F. Supp. 127, 130 (N.D.N.Y. 1998) and Margaret A. Berger, 
Procedural Paradigms for Applying the Daubert Test, 78 Minn. L. Rev. 
1345, 1351 (1994)).

 

[¶9]      Finally, we also 
recognized in Bunting, 984 P.2d  at 471-73, 
three inter-related considerations that should be kept in mind by a trial court 
when performing the Daubert gatekeeping function.  First, the trial court may consider one 
or more of the criteria mentioned in Daubert, but those factors may not 
all be helpful in every case, so the test must remain flexible enough to give 
the trial court broad latitude in determining reliability.  Second, expert testimony must be based 
upon reliable methodology, but it need not be so persuasive as to meet the 
proponent's burden of proof on an issue.  
"Shaky" but admissible evidence can be tested through traditional means, 
such as cross-examination, contrary evidence, and careful jury instruction.  And third, a trial court's exclusion of 
evidence as unreliable is potentially inconsistent with the jury's duty to 
evaluate witness credibility and to assign evidentiary weight.  To avoid usurping the jury's role, the 
trial court should limit its assessment to the soundness of the scientific 
principles and the propriety of the methodology and should not concern itself 
with the scientific validity of the conclusions offered by the 
expert.

 

 

[¶10]   We begin this discussion with a 
reminder of what it is this Court is deciding.  We are not deciding whether trauma can 
cause FM, or even whether, as a general proposition, there is sufficient 
scientific foundation for the theory to allow juries to decide the issue as a 
question of fact.  Rather, under an 
abuse of discretion standard, we are reviewing a district court's determination 
concerning a particular motion in limine.  
For that reason, cases from other jurisdictions that have considered FM 
as an element of damages are informative, but are not of great precedential 
value because different materials were available at the motion hearings in those 
cases.2  The question before us is limited to 
whether this particular trial court, given the evidence and arguments at the 
time, reasonably could have concluded as it did.  The United States Court of Appeals for 
the Tenth Circuit has described the narrowness of such review as 
follows:

 

[W]e 
note that the scope of our review is quite narrow: we may reverse the district 
court's ruling only if we conclude that it abused its discretion in applying 
Daubert to exclude opinions of the Hollanders' experts.  Because the district court has 
discretion to consider a variety of factors is [sic.] assessing 
reliability under Daubert, and because, in light of that discretion, 
there is not an extensive body of appellate case law defining the criteria for 
assessing scientific reliability, we are limited to determining whether the 
district court's application of the Daubert [sic.] manifests a 
clear error of judgment or exceeds the bounds of permissible choice in the 
circumstances.  See McEwen 
[v. City of Norman, Okla.,] 926 F.2d [1539,] 1553-54 [(10th Cir.1991)] 
(discussing appellate review for an abuse of discretion).  Thus, when coupled with this deferential 
standard of review, Daubert's effort to safeguard the reliability of 
science in the courtroom may produce a counter-intuitive effect:  different courts relying on . . . 
essentially the same science may reach different results.  See generally Federal Judicial 
Center, Reference Manual on Scientific Evidence 27 (2d ed.2000) (observing 
that, in light of the abuse of discretion standard of review for Daubert 
determinations of reliability, "in theory judges are free to select 
different procedures and apply different factors to a particular expert or type 
of expertise than their colleagues do in the same district or circuit" and that 
"[a]s a consequence, similar cases could be resolved differently on the basis of 
inconsistent determinations about admissibility"); see also Brasher 
[v. Sandoz Pharmaceuticals Corp.], 160 F.Supp.2d [1291] at 1298 n.17 
[(N.D. Ala.2001)] (observing that the Eighth Circuit's decision in 
Glastetter [v. Novartis Pharmaceuticals Corp.], 252 F.3d [986] at 
989-92 [(8th Cir.2001)], affirming the exclusion of Parlodel evidence as 
unreliable "does not necessarily [establish] that an inconsistent holding by 
this court would constitute an abuse of discretion").

 

Hollander 
v. Sandoz Pharmaceuticals Corp., 289 F.3d 1193, 1206-07 (10th Cir.), cert. denied, 537 U.S. 1088 
(2002).

 

[¶11]   The parties supplied the trial 
court with voluminous materials to assist it in ruling on the motion.3  Based on those materials, the 
respondents presented to the trial court a detailed argument as to why the 
proposed testimony of Drs. Monger and Ockey was inadmissible under Daubert 
scrutiny.  Their essential 
points can be summarized as follows:

 

1.         
Dr. Monger's diagnosis was based on the petitioner's self-reporting, and 
Dr. Monger at first ruled out FM because petitioner's symptoms were not 
consistent with FM.

 

2.         
Dr. Monger admitted that there is no evidence that a single event causes 
FM, but that many physical and emotional stressors may be 
involved.

 

3.         
Dr. Monger admitted that the etiology and pathogenesis of FM are unknown 
to science, and that there are no controlled studies that link FM to trauma.4

 

4.         
Dr. Monger has no specialized training, has taken no specialized classes, 
has authored no articles, and has participated in no studies or research 
involving FM.  Neither has he even 
read the seminal "Consensus Report" on FM.

 

5.         
When asked if he was "aware of any specific scientific standards for 
determining whether causation exists in the medical literature," Dr. Monger 
replied:

 

No.  It's a very controversial syndrome.  And I believe the problem rests 
primarily in that there's no objective test for fibromyalgia.  The diagnosis rests on patient's 
self-reported symptoms.  There's no 
blood test, there's no x-ray, there's no anything else.   So it's controversial.  Because you have to rely on the patient 
to tell you how they're doing, if they hurt, what caused their symptoms and so 
forth.

 

6.         
Dr. Ockey's diagnosis was also based exclusively on the petitioner's 
self-reporting.

 

7.         
Dr. Ockey has never participated in any research studies concerning FM 
and he has not read the "Consensus Report."

 

8.         
Dr. Ockey admitted that neither the cause nor the pathogenesis of FM is 
known in medicine.

 

9.         
Dr. Ockey admitted that he has no internal studies or monitoring to keep 
track of FM patients.

 

10.       The medical 
literature evidences the lack of a scientific foundation for the theory that 
trauma may cause FM.  For 
example:

 

a.         
Dan Buskila, M.D. and Lily Neumann, PhD., Musculosekletal Injury as a 
Trigger for Fibromyalgia/PostTraumatic Fibromyalgia, 104, 105 (Israel 
2000):

 

A 
traumatic incident has been suggested as a possible etiologic factor relating to 
the onset of FM.  Overall data from 
the literature are insufficient to indicate whether causal relationships exist 
between trauma and FM.  The absence 
of evidence, however, does not mean that causality does not exist; rather, it 
posits that appropriate studies have not been performed.

 

b.         
Dan Buskila, Lily Neumann, Genady Vaisberg, Daphna Alkalay, Frederick 
Wolfe, Increased Rates of Fibromyalgia Following Cervical Spine Injury, 
40 Arthritis & Rheumatism 446 (1997) (footnotes 
omitted):

 

Fibromyalgia 
syndrome (FMS) is a chronic, painful musculoskeletal disorder of unknown 
etiology.  A growing body of 
epidemiologic evidence has shown it to be relatively common, occurring in up to 
2% of the general population.  
Despite extensive research, the etiology and pathophysiology of FMS are 
still unclear.  Disturbances in 
stage 4 sleep, hormonal and infectious factors, and stressful conditions have 
been suggested as possible progenitors.  
Although equivocal, some evidence has suggested that biomechanical 
disturbances in the cervical spine may play a role in the pathogenesis of 
FMS.  Evidence that trauma can cause 
FMS comes from a few case series or case reports and is insufficient to 
establish causal relationships.

 

c.         
Wolfe, supra, 23 Journal of Rheumatology at 534 (footnotes 
omitted):

 

FM 
in the setting of work disability or compensation has been the subject of a 
number of reports.  While the 
association between work disability or compensation and FM is well established, 
data regarding causality are largely absent.  The clinical dilemma, whether an injury 
or workplace stress caused the patient's FM, a retrodictive (or It Did) causal 
proposition can rarely be determined to be certainly true or certainly 
false.  Evidence that trauma can 
cause FM, a potential (or It Can) causal proposition, comes from a few case 
series or case reports and is insufficient to establish causal 
relationships.  That trauma might 
cause FM sometimes, a predictive (or It Will) causal proposition, can only be 
addressed by epidemiological studies that measure the risk of potential 
exposures on the development of FM.  
Epidemiologic studies of trauma and FM needed to address potential or 
predictive causality are currently not available.

 

11.       No leading 
case with precedential value has ruled admissible expert testimony to the effect 
that trauma causes FM.  See 
Black, 171 F.3d 308.

 

[¶12]   In their appellate briefing, the 
respondents have reiterated the foregoing arguments and they have chronicled the 
trial court's painstaking application of the Daubert principles in 
rendering its decision.  In 
addition, the respondents have referenced the deposition of their designated 
expert, John Rice, M.D., a Duke University Medical Center associate professor 
who has specialized in the study of FM, who participated in the conference 
resulting in the "Consensus Report," and who is of the opinion that the 
petitioner's FM symptoms were not caused by the automobile accident.  Finally, the respondents have pointed 
out what they consider to be a major flaw in the opinions of the petitioner's 
experts:  for the "differential 
diagnosis" methodology utilized by Drs. Ockey and Monger to be reliable, one 
must be able not only to "rule out" other causes, but to "rule in" the alleged 
cause:

 

[W]e 
conclude that the district court did not abuse its discretion.  In many of the decisions in which a 
differential diagnosis has been deemed reliable, the party relying on the 
diagnosis has offered independently reliable evidence that the allegedly 
dangerous drug or substance had harmful effects.  See, e.g., Zuchowicz v. United 
States, 140 F.3d 381, 385-87 (2d Cir.1998) (affirming admission of 
differential diagnosis based in part on scientific articles regarding the 
effects of a drug); Kennedy v. Collagen Corp., 161 F.3d 1226, 1228-30 
(9th Cir.1998) (holding that the district court abused its discretion in 
excluding expert opinion based on differential diagnosis when the diagnosis was 
supported by scientific and clinical studies regarding the connection between 
collagen and autoimmune disorders).  
That is not the case here.  
In order to "rule in" Parlodel as a scientifically plausible cause of Ms. 
Hollander's stroke, the Hollanders' experts would need to present reliable 
evidence that the drug can cause strokes, and for the reasons we have discussed, 
the district court did not abuse its discretion in concluding that the experts 
did not do so.  See Glastetter 
[v. Novartis Pharmaceuticals Corp., 252 F.3d 986] at 989 [8th 
Cir.2001)] (affirming the district court's exclusion of a differential 
diagnosis); cf. Siharath [v. Sandoz Pharmaceuticals Corp.,] 131 
F.Supp. [1347] at 1362-63 [(N.D. Ga.2001)] ("[A] fundamental assumption 
underlying this method is that the final, suspected cause' remaining after this 
process of elimination must actually be capable of causing the injury.  That is, the expert must rule in' the 
other suspected cause as well as rule out' other possible causes.  And, of course, expert opinion on this 
issue of general causation must be derived from scientifically valid 
methodology.")

 

Hollander, 
289 F.3d  at 1210-11.  In other words, a physician cannot, by 
ruling out other causes, conclude that an automobile accident caused a patient's 
FM, where there is no scientific basis for the conclusion that physical trauma 
can cause FM.

 

[¶13]   The materials presented by the 
petitioner in opposition to the respondents' motion are included in the listings 
in footnotes 2 and 3 hereinabove.  
Based on those materials, the petitioner countered the respondents' 
position with a detailed argument as to why Drs. Monger and Ockey should be 
allowed to testify.  The main points 
of that argument can be summarized as follows:

 

1.         
Dr. Monger is a board-certified rheumatologist, which is the area of 
expertise in which FM is treated, and he has treated the petitioner for 
years.

 

2.         
Dr. Monger made a complete differential diagnosis of the petitioner's FM 
symptoms and ruled out all causes other than physical trauma from the automobile 
accident.

 

3.         
In reaching his conclusion that the automobile accident had caused the 
petitioner's FM, Dr. Monger considered her pre- and post-accident medical 
history, as well as case reports of other persons "who develop fibromyalgia 
after trauma such as a motor vehicle accident."

 

4.         
Although Dr. Ockey is not a rheumatologist, there is considerable 
"overlap" between the chronic pain portion of rheumatology and his specialty, 
which is physical medicine and rehabilitation.

 

5.         
Eighty to ninety percent of Dr. Ockey's practice deals with chronic pain, 
and he sees a significant number of patients suffering from 
FM.

 

6.         
After a complete differential diagnosis of the petitioner's FM symptoms, 
Dr. Ockey diagnosed their cause as being physical trauma from the automobile 
accident.  That diagnosis was based 
on the petitioner's reporting, his experience over the years, and medical 
literature.

 

7.         
Recent medical literature contains support for the theory that physical 
trauma can cause FM.  For 
example:

 

a.         
Fibromyalgia Syndrome, Arthritis Foundation at 7 (undated 
pamphlet):

 

Many 
different factors, alone or in combination, may trigger fibromyalgia.  For example, a number of stresses  such 
as illness, emotional trauma, physical trauma or hormonal changes  may lead to 
the generalized pain, fatigue and non-restful sleep that characterize 
fibromyalgia.

 

Physical 
or emotional trauma can trigger fibromyalgia.  For example, an infection, a case of the 
flu, or a car accident could lead to this syndrome.  People with fibromyalgia may become 
inactive and anxious about their health, further aggravating the 
disorder.[5]

 

b.         
Don L. Goldenberg, M.D., Pathogenesis and Treatment of 
Fibromyalgia, 9 Up to Date (2001):  "There is no evidence that a single 
event causes' fibromyalgia.  
Rather, many physical and/or emotional stressors may trigger or aggravate 
symptoms.  These have included 
certain infections, such as a viral illness or Lyme disease, or physical 
trauma."

 

c.         
Robert M. Bennett, The Fibromyalgia Syndrome, Textbook of 
Rheumatology 511, 513 (5th ed.) (emphasis in 
original):

 

Patients 
frequently attribute an "event" to the onset of their symptoms.  Attribution and rationalization are 
common human traits and correlation does not equal 
causation.  
Events that have been linked to the onset of fibromyalgia include 
flu-like illness, human immunodeficiency virus (HIV) infection, parvo-virus 
infection, Lyme disease, toxic oil syndrome, persistent stress, chronic sleep 
disturbance, and physical trauma.

 

d.         
Buskila and Neumann, supra, at 106 (quoting D.J. Clauw and 
G.P. Chrousos, 4 Chronic Pain and Fatigue Syndromes 134-53 
(1997)) (footnotes 
omitted):

 

Despite 
intensive research, major gaps in our understanding of the pathogenesis and 
etiology of FM still remain.  
Environmental triggers, including various emotional, immune, and physical 
trauma, have been implicated in the development of FM.  Clauw and Chrousos emphasize that FM can 
be initiated by many triggers, all of which fall into the general category of 
"stressors."  Thus, FM may be 
triggered or worsened by physical trauma, such as [motor vehicle 
accidents].

 

e.         
Buskila, Neumann, Vaisberg, Alkalay, Wolfe, supra, 40 Arthritis 
& Rheumatism at 446: 
"FMS [fibromyalgia syndrome] was 13 times more frequent following neck injury 
than following lower extremity injury.  
All patients continued to be employed, and insurance claims were not 
increased in patients with FMS."6

 

f.          
Bruce Freundlich and Lawrence Leventhal, The Fibromyalgia Syndrome, 
Primer on Rheumatic Diseases 124, 125 Arthritis Foundation:

 

Muscular 
strain of the upper torso from motor vehicle accidents or sports injuries may 
produce aching and stiffness that simulates FMS with a limited number of tender 
points.  Although FMS may initially 
be absent following an injury, these limited symptoms may persist causing 
disturbed sleep, and FMS may develop as a secondary process over 
time.

 

[¶14]   In her appellate briefing, the 
petitioner has buttressed her trial court position with two particular 
points.  First, the petitioner 
contends that differential diagnosis "is a standard scientific technique of 
identifying the cause of a medical problem by eliminating the likely causes 
until the most probable cause is isolated."  Westberry v. Gislaved Gummi AB, 
178 F.3d 257, 262 (4th Cir. 1999).  See also Heller v. Shaw Industries, 
Inc., 167 F.3d 146, 156 (3rd Cir. 1999).  Where an expert's opinion is based on 
his treatment of the patient, the patient's medical history, the physician's 
training and experience, and the use of differential diagnosis, a lack of 
textual authority for his opinion goes to the weight, not the admissibility, of 
the testimony.  McCullock v. H.B. 
Fuller Co., 61 F.3d 1038, 1044 (2nd Cir. 1995).  See also Alder v. Bayer Corp., AGFA 
Div., 2002 UT 115, 61 P.3d 1068, 1083-85 (Utah 2002).

 

[¶15]   Next, the petitioner points out 
that the trial court did not appear to consider criticism of the "Consensus 
Report" found in Muhammad B. Yunus, Robert M. Bennett, Thomas J. Romano, I. Jon 
Russell, et al.,  Fibromyalgia 
Consensus Report: Additional Comments, 3 Journal of Clinical Rheumatology 
324, 324-25 (1997) (quoting D.L. Sackett, W.M.M. Rosenberg, J.A.M. Gray, 
R.B. Haynes, W.S. Richardson, Evidence Based Medicine:  What It Is and What It Isn't 
(1996)) (footnotes omitted and emphasis in 
original):

 

            
With regard to injury and FMS [fibromyalgia syndrome], the Report 
emphasizes scientific causality and becomes involved in the jargons of 
retrodictive and predictive causal propositions.  Causal propositions are rarely 
established with absolute certainty in the realm of medicine.  An alternative (and better known) model 
is the consideration of consistency of association, strength of association, 
dose-response relationship, and biologic plausibility.  . . .  Additionally, the concept of 
evidence-based medicine integrate both data-based 
information and astute clinical observations.  The comments of Sackett et al., on 
evidence-based medicine is worth noting:  
"Good doctors use both individual clinical expertise and the best 
available external evidence, and neither alone is enough.  Without clinical expertise, practice 
risks becoming tyrannized by evidence. . .."

 

            
In the context of a legal setting (where the Consensus Report is likely 
to be used), causality entails only 51% certainty, usually stated in terms of 
reasonable medical probability.  
Based on a consistent clinical pattern, case-control or descriptive 
studies, and biologic plausibility of central nervous system plasticity, it 
seems more than 51% likely that trauma does play a causative role in some FMS 
patients, as agreed by other independent observers.  That trauma can cause localized or 
regional musculoskeletal pain is not arguable, rather the question is:  can regional pain and tenderness become 
widespread?  The biologic 
plausibility of such a spread of pain and tenderness is now supported by changes 
in the central nervous system (neuroplasticity), as well documented in animals 
(that have no obvious secondary gain!) and in humans.

 

[¶16]   The trial court issued a four-page 
decision letter upon which the order granting the motion in limine was 
based.  The trial court noted 
Wyoming's adoption of Daubert in Bunting, and then applied the 
four non-exclusive Daubert tests to the facts at 
hand:

 

The 
premise that trauma causes fibromyalgia has not been adequately tested.  Dr. Monger acknowledged that there are 
no controlled studies that connect fibromyalgia to trauma.  Dr. Monger said he knew of some reports 
where fibromyalgia occurred after trauma, but apparently those were anecdotal 
reports rather than statistically valid studies.

 

Dr. 
Ockey identified a study by Buskila as pointing to a causal connection, but had 
not read the study.  Dr. Ockey 
agreed that "there are certain things associated with it (fibromyalgia), but the 
cause is not known."

 

Medical 
literature indicates a lack of testing.  
D. Buskila, one of the scientists who conducted the study Dr. Ockey knew 
about, concludes that "evidence that . . . trauma can cause FM comes from a few 
case series or anecdotal case reports. . . .  (D)ata are insufficient to indicate 
whether causal relationships exist between trauma and FM."  Buskila and Neumann, 
Musculoskeletal Injury as a Trigger for Fibromyalgia/Post-Traumatic 
Fibromyalgia.

 

The 
peer review information presented to the Court indicates a controversy over 
traumatic cause of fibromyalgia, with a consensus report from many experts 
concluding that "epidemiological studies of trauma and FM needed to address 
potential or predictive causality are currently not available.  . . .  The cause(s) of FM are incompletely 
understood.  There may be events 
reported by the patient as precipitating and/or aggravating, including physical 
trauma, emotional trauma, infection, surgery and emotional or physical 
stress."  The Fibromyalgia 
Syndrome: A Consensus Report on Fibromyalgia and Disability, Journal of 
Rheumatology 534-537, 1996.

 

The 
Plaintiff was unable to provide any study or peer review which concluded that 
trauma caused fibromyalgia.  She 
provided a monograph from the National Fibromyalgia Partnership, Inc., which 
states that "fibromyalgia syndrome often develops after a physical trauma."  That document states that trauma 
may cause physiological changes which in turn result in 
fibromyalgia.  This information is 
insufficient to establish peer review support for the theory that trauma causes 
fibromyalgia.

 

Plaintiff 
also points to a statement in the 1996 Consensus Report that physicians should 
consider the patient's opinion along with collateral information in determining 
the relationship between fibromyalgia and trauma.  This statement does not constitute peer 
review or general acceptance of the proposition that trauma causes 
fibromyalgia.  To the contrary, it 
indicates that if a doctor must determine whether a causal relationship exists 
he/she must use non-scientific information and methods.

 

No 
evidence established an error rate for any causation study results because no 
studies were presented.  Calculating 
an error rate may be extremely difficult because a myriad of factors may 
contribute to fibromyalgia and because any physiologic basis for fibromyalgia is 
unknown.

 

The 
literature indicates that a causal connection between trauma and fibromyalgia is 
not generally accepted.  Although 
scientists acknowledge the potential for a link, they consistently indicate that 
such a cause-effect connection has not been scientifically 
established.

 

Although 
the four Daubert factors are not exclusive, no other evidence gives 
scientific credibility to the theory that trauma from the accident caused 
fibromyalgia.  Although both of 
Plaintiff's physicians offered an opinion that trauma did cause fibromyalgia, 
those opinions are based on subjective beliefs rather than on 
science.

 

(Emphasis 
in original.)

 

CONCLUSION

 

[¶17]   The trial court concluded that 
the proffered opinions of Drs. Monger and Ockey lacked scientific 
reliability.  Applying Daubert, 
the trial court found that the theory of a causal link between physical 
trauma and FM has not adequately been tested and has not been subjected to 
sufficient peer review.  Further, 
there have been no controlled studies, so no error rate has been 
established.  After examining the 
materials presented to it, the trial court determined that the controversy over 
trauma-induced FM evidenced a lack of general acceptance of the theory within 
the medical community.  
Consequently, the expert testimony was ruled 
inadmissible.

 

[¶18]   There are, however, countervailing 
facts and principles that must be considered.  Clearly, differential diagnosis is an 
accepted method of diagnosing FM.  
Furthermore, some medical experts believe that physical trauma can cause 
FM.  In that sense, the proposed 
expert's opinion cannot be said to be novel, either in approach or in 
conclusion.7  Drs. Monger and Ockey are both well 
informed about FM, through training or experience, and both are the petitioner's 
treating physicians, rather than litigation-inspired 
experts.

 

[¶19]   It is appropriate at this juncture 
to revisit two of the considerations raised in Bunting, 984 P.2d  at 
471-73.  First, expert testimony must be based on 
reliable methodology, but it need not be so persuasive as to meet the 
proponent's burden of proof.  
Admissibility is just the first hurdle.  Once admitted, expert testimony is 
subject to all the traditional means of testing evidence.  And second, if the admissibility bar is 
raised too high, the court usurps the jury's duty to evaluate the expert's 
credibility and weigh the evidence.  
So long as the expert has reliable grounds for reaching his conclusion, 
his opinion is admissible, whether or not the court agrees with the expert's 
conclusion.  Bunting, 984 P.2d  at 473; 
Heller, 167 F.3d  at 156.

 

[¶20]   In the instant case, the proffered 
expert opinions were based on the petitioner's self-reported symptoms, filtered 
through the two doctors' perceptions after years of experience with similar 
patients.  The opinions were given 
in the overall context of a professional controversy over the link between 
physical trauma and FM, in which some experts take the position that there is, 
indeed, a causal connection.  We 
conclude that, under these circumstances, the trial court abused its discretion 
in not allowing the jury to determine the weight to give the opinion 
testimony.

 

[¶21]   We reverse and remand to the trial 
court for further proceedings consistent with this 
opinion.

 
LEHMAN, 
Justice, dissenting.

 

[¶22]   I agree with the majority's 
recitation of relevant law but disagree with the reasoning used in reaching its 
ultimate determination given the facts and circumstances that exist.  Accordingly, I respectfully 
dissent.  

 

[¶23]   I am in accord that the ultimate 
issue is whether the trial court reasonably could have concluded as it did or 
whether it exceeded the bounds of reason under the circumstances when it granted 
respondents' motion in limine to exclude expert testimony.  I also agree that when faced with such a 
determination, a trial court must act as a "gatekeeper" to determine the 
reliability of the proffered expert testimony by applying the flexible criteria 
set forth in Bunting v. Jamieson, 984 P.2d 467, 471-73 (Wyo. 1999) 
(formally adopting in Wyoming the four non-exclusive tests to the facts at hand 
enunciated in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 
592-94, 113 S. Ct. 2786, 2796-97, 125 L. Ed. 2d 469 (1993)).   

 

[¶24]   Perhaps most importantly, I embrace 
the proposition that a trial court must be given broad latitude in determining 
whether expert testimony is based upon reliable scientific methodology so as to 
make those conclusions offered by an expert admissible.  Thus, as noted by the majority, quoting 
the United States Court of Appeals for the Tenth Circuit in Hollander v. 
Sandoz Pharmaceuticals Corp., 289 F.3d 1193, 1206-07 (10th Cir.), cert. denied 537 U.S. 1088, 123 S. Ct. 697, 154 L. Ed. 2d 632 (2002), our scope in reviewing such issues is 
very narrowlimiting our reversal of the trial court's decision solely if we 
conclude that it abused its discretion in excluding expert 
testimony.

 

[¶25]   Here, as admitted by the majority, 
the trial court was presented with voluminous materials to assist in its ruling 
on the motion and ultimately made a detailed and painstaking application of the 
Daubert principles before rendering its decision.  Upon my review of the analysis expressed 
in its four-page decision letter, I simply cannot conclude that the trial court 
clearly abused its discretion in rendering its decision.  To the contrary, the trial court, based 
on the specific materials provided, reasonably determined that the literature 
was insufficient to scientifically establish that a cause-effect connection 
exists between trauma and fibromyalgia (FM) and that, despite intensive 
research, major gaps in our understanding of the pathogenesis and etiology of FM 
remain.  

 

[¶26]   Furthermore, while I am not 
diametrically opposed to the utilization of "differential diagnosis" methodology 
by medical experts in rendering opinions on legal causation, I believe that such 
use must be carefully monitored.  As 
disclosed by the majority, a fundamental assumption underlying this method is 
that the final, suspected "cause" remaining after this process of elimination is 
applied must actually be capable of causing the injury derived from 
scientifically valid methodology.  
In other words, the expert must be able to "rule in" the suspected cause, 
as well as "rule out" other possible causes based on an established scientific 
foundation.  Upon my independent 
review, I conclude that the trial court did not unreasonably determine that such 
evidence was not presented in this case.

 

[¶27]   Therefore, I would affirm the 
ruling of the trial court granting the motion in limine excluding the proffered 
expert testimony on the basis of its unproven scientific 
reliability.

 

FOOTNOTES

 

  1The purpose of a motion in limine is 
to obtain the court's pretrial ruling on the admissibility of evidence.  W.R.C.P. 56(d) goes beyond that purpose 
to include the court's pretrial ruling on what facts are, and are not, in 
controversy.

 

  2The following published FM cases 
were cited to the trial court:  
Walker v. American Home Shield Long Term Disability Plan, 180 F.3d 1065 (9th Cir. 1999) (admissibility of testimony as to causal 
link between trauma and FM not an issue; issue whether plaintiff disabled as a 
result of FM); Black, 171 F.3d 308 (abuse of discretion to allow board 
certified physician to testify that a slip-and-fall caused FM); Licciardi v. 
TIG Ins. Group, 140 F.3d 357 (1st Cir. 1998) (admissibility of testimony as to causal 
link between trauma and FM not an issue; issue is expert testimony beyond 
designation); Lang v. Long-Term Disability Plan of Sponsor Applied Remote 
Technology, Inc., 125 F.3d 794 (9th Cir. 1997) (admissibility of testimony as to causal 
link between trauma and FM not an issue; issue whether plaintiff's depression 
was FM-related); Minner v. American Mortg. & Guar. Co., 791 A.2d 826 
(Del.Super. 2000) (temporal relationship insufficient to 
establish causal link between a building's condition and FM); Hughes v. 
Scottsdale Ins. Co., 793 So. 2d 537 (La.App. 2001) (admissibility of testimony as to causal 
link between trauma and FM not an issue; issue whether evidence sufficient to 
prove accident caused FM); Young v. Hickory Business Furniture, 353 N.C. 
227, 538 S.E.2d 912 (2000) (maxim post hoc, ergo propter 
hocafter this, therefore because of thisinsufficient to establish causal 
link between trauma and FM).  The 
following unpublished cases were also cited to the trial court:  Byrum v. Superior Court, Los Angeles 
County, 2002 WL 243565 (Cal.App. 2002) (testimony as to causal link between 
trauma and FM not subject to state's non-Daubert reliability standard 
because not based on new or novel scientific theory or device); Hultberg v. 
Wal-Mart Stores, Inc., 1999 WL 244030 (E.D.La. 1999) (testimony that slip-and-fall caused FM 
unreliable); Shepler v. Love, 2001 WL 1104811 (Ohio App. 
2001) (admissibility of testimony as to causal 
link between trauma and FM not an issue); Jones v. Conrad, 2001 WL 
1001083 (Ohio App. 2001) (treating physician's testimony that 
trauma caused FM inadmissible because not scientifically reliable).  In her appellate briefing, the 
petitioner has also cited Alder v. Bayer Corp., AGFA Div., 2002 UT 115, 
61 P.3d 1068 (Utah 2002) (expert testimony as to FM causation not 
rendered inadmissible by conflict among experts, so long as the testifying 
expert's methodology, such as differential diagnosis, is a standard 
practice).

 

  3In addition to the petitioner's 
medical records and the depositions of Drs. Ockey and Monger, the following 
items were provided to the trial court, for some of which full source 
information is not reflected in the record:  Dan Buskila, M.D. and Lily Neumann, 
PhD., Musculoskeletal Injury as a Trigger for Fibromyalgia/PostTraumatic 
Fibromyalgia 104 (Israel 2000); 
Wolfe, supra, 23 Journal of Rheumatology 534; 
Fibromyalgia Syndrome, Arthritis Foundation (undated 
pamphlet); 
Dan Buskila, Lily Neumann, Genady Vaisberg, Daphna Alkalay, Frederick Wolfe, 
Increased Rates of Fibromyalgia Following Cervical Spine Injury, 40 
Arthritis & Rheumatism 446 (1997); 
Leslie A. Aaron, Laurence A. Bradley, Graciela S. Alarc³n, Mireya 
Triana-Alexander, Ronald W. Alexander, Michelle Y. Martin, Kristin R. Alberts, 
Perceived Physical and Emotional Trauma as Precipitating Events in 
Fibromyalgia, 40 Arthritis & Rheumatism 453 (1997); 
Kevin P. White, Simon Carette, Manfred Harth, Robert W. Teasell, Trauma and 
Fibromyalgia: Is There an Association and What Does It Mean, 29 Seminars in 
Arthritis & Rheumatism 200 (2000); 
Don L. Goldenberg, M.D., Clinical Manifestations and Diagnosis of 
Fibromyalgia, 9 Up to Date (2000); 
Don L. Goldenberg, M.D., Differential Diagnosis of Fibromyalgia, 9 Up to 
Date (2000); 
Don L. Goldenberg, M.D., Pathogenesis and Treatment of Fibromyalgia, 9 Up 
to Date (2001); 
Don L. Goldenberg, Patient Information: Fibromyalgia, 9 Up to Date 
(2000); 
Robert M. Bennett, The Fibromyalgia Syndrome, Textbook of Rheumatology 
511 (5th ed.); 
Criteria for the Classification of Fibromyalgia, Primer on Rheumatic 
Diseases 457, adapted from F. Wolfe, HA Smythe, MB Yunus, et al., American 
College of Rheumatology (1990); 
Bruce Freundlich and Lawrence Leventhal, The Fibromyalgia Syndrome, 
Primer on Rheumatic Diseases 124, Arthritis Foundation; 
Muhammad B. Yunus, Robert M. Bennett, Thomas J. Romano, I. Jon Russell, et al., 
Fibromyalgia Consensus Report: Additional Comments, 3 Journal of Clinical 
Rheumatology 324 (1997).

 

  4"Etiology" refers to the cause and 
origin of a disease.  "Pathogenesis" 
refers to the origination and development of a disease.  Webster's Third New International 
Dictionary of the English Language Unabridged 782, 1655 (1993).

 

  5This language, which was quoted in 
the petitioner's memorandum of law in the trial court, comes from a copy of the 
Arthritis Foundation brochure attached as an exhibit to Dr. Monger's 
deposition.  Dr. Monger's 
deposition, including the brochure, is attached to the petitioner's memorandum 
of law as Exhibit 1.  Interestingly 
enough, attached to the memorandum of law as Exhibit 5 is a similar brochure 
from the Arthritis Foundation, with the same title, which contains the following 
version of the same section on FM causation:

 

No 
one knows what causes fibromyalgia.  
Researchers speculate that many different factors, alone or in 
combination, may cause fibromyalgia.  
For example, factors such as an infectious illness, physical trauma, 
emotional trauma or hormonal changes, may contribute to the generalized pain, 
fatigue and sleep disturbances that characterize the 
condition.

 

Studies 
have suggested that people with fibromyalgia have abnormal levels of several of 
the different chemicals that help transmit and amplify pain signals to and from 
the brain.  Whether these 
abnormalities are a cause or a result of fibromyalgia is 
unknown.

 

Clearly, 
this is a far weaker statement that FM may be linked to physical trauma.  Neither version of the brochure 
contained in the record bears a publication date, so there is no evidence as to 
which may reflect the more recent position of the Arthritis 
Foundation.

 

  6In this study, patients with neck 
injuries were compared to patients with lower extremity injuries.  The second quoted sentence refers to one 
aspect of the study wherein it was determined that the patients suffering from 
FM did not file insurance claims at a higher rate than did those patients not 
suffering from FM, nor were they unemployed at a higher 
rate.

 

  7Even a novel conclusion is not 
necessarily inadmissible.  
Heller, 167 F.3d  at 156.