Title: Black v. Bladergroen

State: virginia

Issuer: Virginia Supreme Court

Document:

Present:  All the Justices 
 
FRED S. BLACK 
                        OPINION BY  
v.  Record No. 990065      CHIEF JUSTICE HARRY L. CARRICO 
                        November 5, 1999 
MARK R. BLADERGROEN, M.D., ET AL. 
 
FROM THE CIRCUIT COURT OF THE CITY OF RICHMOND 
Randall G. Johnson, Judge 
 
 
In this medical malpractice case, the sole question 
for decision is whether the trial court erred in excluding 
the testimony of a medical expert called by the plaintiff.  
Finding the trial court’s action erroneous, we will 
reverse. 
 
In a motion for judgment filed October 17, 1996, the 
plaintiff, Fred S. Black, sought to recover damages from 
the defendants, Mark R. Bladergroen, M.D., Harold J. 
Levinson, M.D.,1 Thomas P. Christopher, M.D., and Cardiac 
Surgical Associates, Ltd.2  In the motion for judgment,  the 
plaintiff alleged that the individual defendants, Drs. 
Bladergroen, Levinson, and Christopher, were duly licensed 
physicians who carried on a practice of cardiac surgery in 
the employment of the corporate defendant, Cardiac Surgical 
                     
1 Upon Dr. Levinson’s death on November 3, 1997, his 
executrix, Heidi S. Levinson, was substituted as a party 
defendant in his place. 
2A number of other health care providers were also 
named as defendants, but they were dismissed from the case 
on motions for summary judgment or voluntary nonsuit and 
are not parties to this appeal.  
Associates, Ltd.  The plaintiff alleged further that the 
defendants’ negligence resulted in the amputation of his 
right leg during a period of hospitalization in 1994.  
A jury trial resulted in a verdict in favor of the 
defendants, upon which the trial court entered judgment.  
We awarded the plaintiff this appeal.  
Prior to the events in question, the plaintiff had 
suffered from heart disease for some time and had endured 
two heart attacks.  In October 1994, he experienced pain 
and was admitted to Henrico Doctors Hospital, where he came 
under the care of the defendant physicians.  Following 
cardiac bypass surgery, he developed complications.  His 
blood pressure dropped to dangerously low levels, and he 
had problems with circulation in his right leg.  When the 
circulatory problems could not be corrected, the leg was 
amputated.  The plaintiff was diagnosed as having suffered 
an anaphylactic reaction, which set off a chain of events 
resulting in the loss of the leg. 
During his case-in-chief, the plaintiff called W. 
Dudley Johnson, M.D., a board-certified thoracic surgeon 
from Milwaukee, Wisconsin, to testify as an expert on the 
standard of care applicable to the defendants’ treatment of 
the plaintiff.  On voir dire examination, Dr. Johnson 
stated that he attended the University of Illinois Medical 
 
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School, and, after finishing medical school and an 
internship, entered surgical training, which consisted of 
four years of general surgery and two years of heart 
surgery.  He was an associate clinical professor of surgery 
at the medical school in Milwaukee, belonged to numerous 
medical associations and societies, and had served on the 
Wisconsin State Medical Licensing Board, in which capacity 
he examined the credentials of “[a]ll kinds of physicians . 
. . from all over the country and around the world” who 
wanted to come to Wisconsin to practice medicine. 
Dr. Johnson testified further that he “initially 
developed and perfected the modern [coronary] bypass 
operation [which] is now done throughout the world” and 
that he was “the first person to put in two, three, four, 
five, six bypasses” and the first to “describe secondary 
operations and . . . third and fourth operations for 
coronary disease.”  He said that he personally had 
performed between eight and nine thousand cardiac 
operations, that he had operated in eight or nine foreign 
countries, and that patients had come to him for surgery 
from approximately thirty-five foreign countries and every 
state in the union.  He also said that “around 68” of his 
patients had come from Virginia and that he had operated on 
“47 or 48” of them.  He had reviewed the records of his 
 
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Virginia patients and had communicated with their Virginia 
surgeons and cardiologists regarding their care and 
treatment. 
When asked on direct examination whether he was 
“familiar with the standard of care that would have been 
adhered to by a reasonably prudent board-certified 
cardiothoracic surgeon practicing in Virginia in 1994,” Dr. 
Johnson said, “Yes.”  When asked to tell the jury “how [he 
had] that familiarity,” he stated: “Because all the 
surgeons in the country take the same required exams.  
There is one national board and one national certification 
for heart surgeons.  We don’t have a certification for 
heart surgeons in Wisconsin.  I don’t know of any state 
that has separate certifications for any specialty.”   
On redirect examination, Dr. Johnson testified he knew 
what the Virginia standard of care is because of his 
“background and experience and several years on [the 
Wisconsin] medical board [reviewing credentials of all] 
kind of physicians . . . from all over the country” and 
because Virginia cardiothoracic surgeons “have to go 
through the same training and take the same exams as every 
other thoracic surgeon . . . in the country.”  When asked 
whether “there is any board certification of thoracic 
 
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surgeons applicable only to Virginia,” he answered, “No . . 
. [t]hey took the same ones I took.  National exams.”        
 In urging the trial court to exclude the testimony of 
Dr. Johnson, the defendants offered no evidence of their 
own.  Instead, they relied solely on  testimony he gave on 
cross-examination.  In response to defense counsel’s 
questions, Dr. Johnson stated that he had never been 
licensed to practice in Virginia, that he had never 
performed surgery in Virginia, and that he had neither 
demonstrated nor witnessed heart surgery performed in 
Virginia.  He stated that while he had discussed topics 
relating to cardiac surgery in general with cardiac 
surgeons at national or regional meetings, he was “not 
certain whether any of those cardiac surgeons actually 
practice in Virginia.”  He admitted he could not name any 
patient referred to him from Virginia with a history 
similar to the plaintiff’s.  And, finally, in what the 
defendants term a “concession,” he said he thought he was 
familiar with the Virginia standard of care for cardiac 
surgeons because he believed “there is a national standard 
of care applicable.” 
On appeal, citing Bly v. Rhoads, 216 Va. 645, 222 
S.E.2d 783 (1976), the defendants say this Court “has 
firmly rejected the availability in Virginia of a recourse 
 
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in a medical malpractice action to a national standard of 
care” on the ground it is for the General Assembly to 
decide whether there should be a national standard.  Id. at 
652-53, 222 S.E.2d at 789; see also Poliquin v. Daniels, 
254 Va. 51, 55, 486 S.E.2d 530, 533 (1997); Henning v. 
Thomas, 235 Va. 181, 186, 366 S.E.2d 109, 112 (1988).  In 
Bly, we said a community standard of care applied in 
Virginia.  However, following Bly, the General Assembly 
enacted Code      § 8.01-581.20 and established a statewide 
standard.  1979 Va. Acts ch. 325.   
We have no intention of retreating from the position 
we took in Bly that it is for the General Assembly to say 
whether a national standard of care should apply in 
Virginia and, hence, we have no inclination to adopt such a 
standard ourselves.  But nothing in Bly or any other 
provision of law prohibits Virginia physicians from 
practicing according to a national standard if one exists 
for a particular specialty, even though neither the General 
Assembly nor this Court has adopted such a standard.    
Moreover, the law concerning medical experts has 
changed since we decided Bly.  In an amendment to Code § 
8.01-581.20, the General Assembly created a presumption 
that favors the admissibility of the testimony of medical 
experts, including out-of-state experts.  1989 Va. Acts ch. 
 
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146.  Thus, the question in this case is simply whether Dr. 
Johnson’s statements on cross-examination, including his 
“concession” in which he related the Virginia standard of 
care to the standard elsewhere, were sufficient to overcome 
the presumption provided by Code § 8.01-581.20.  
The statutory language creating the presumption reads 
as follows: 
Any physician who is licensed to practice in  
Virginia shall be presumed to know the statewide  
standard of care in the specialty or field of  
medicine in which he is qualified and certified. 
This presumption shall also apply to any  
physician who is licensed in some other state of  
the United States and meets the educational and  
examination requirements for licensure in  
Virginia.  [Emphasis added.] 
  
The defendants raise a preliminary question.  They 
argue that the plaintiff failed to establish Dr. Johnson’s 
entitlement to the presumption provided by Code § 8.01-
581.20.  However, Dr. Johnson was asked on  his voir dire 
examination whether he “possess[ed] the qualifications to 
take the Virginia licensing to become licensed in 
Virginia,” and he replied, “I believe I do, yes, sir.”   
At the conclusion of the voir dire hearing, the trial 
court refused to allow Dr. Johnson to testify.  The 
refusal, however, was not on the ground the doctor was not 
entitled to the presumption but because he lacked 
familiarity with the Virginia standard of care.  
 
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 The next day, the plaintiff offered into evidence a 
sworn letter from the Commonwealth’s Department of Health 
Professions, Board of Medicine, stating that Dr. Johnson’s 
credentials “meet the educational and examination 
requirements for licensure in Virginia.”  The trial court 
refused to admit the letter on the ground it came too late, 
but, when the plaintiff’s counsel asked the trial judge 
whether he “accepted the [previous day’s] testimony of Dr. 
Johnson that he met the educational and examination 
requirements for licensure,” the judge stated:  “I accept 
that testimony.”  
The defendants failed to make any objection in the 
trial court to Dr. Johnson’s testimony concerning his 
qualifications for licensure, to the trial judge’s  
acceptance of that testimony, or to the sufficiency of the 
evidence offered to invoke the presumption provided by Code 
§ 8.01-581.20.  Because the defendants raise the question 
whether the plaintiff established Dr. Johnson’s entitlement 
to the presumption for the first time on appeal, we will 
not consider the question.  Rule 5:25.   
This brings us to the question whether the defendants 
rebutted the presumption provided by Code  § 8.01-581.20.  
The trial court held that the defendants had overcome the 
presumption by showing on cross-examination of Dr. Johnson 
 
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that he “has never talked to anyone in Virginia, he never 
practiced in Virginia, [and] he has never read about what 
the standard of care is in Virginia.”  However, Dr. Johnson 
stated that he had reviewed the records of his Virginia 
patients and had communicated with their surgeons and 
cardiologists about their treatment; the presumption 
provided by Code § 8.01-581.20 is not predicated upon 
previous practice in Virginia; and the evidence showed that 
there was no “such thing as a Virginia textbook of 
cardiothoracic surgery” for Dr. Johnson to read.   
Furthermore, “there is no rigid formula to determine 
the knowledge or familiarity of a proffered expert 
concerning the Virginia standard of care.  Instead, that 
knowledge may derive from study, experience, or both.”  
Henning v. Thomas, 235 Va. at 186, 366 S.E.2d at 112.  Dr. 
Johnson’s extensive “background and experience” and his 
familiarity with the manner of practice of “[a]ll kind of 
physicians   . . . from all over the country” offset any 
effect the shortcomings perceived by the trial court may 
have had upon the presumption.   Hence, the matters listed 
by the trial court were insufficient to overcome the 
presumption. 
Neither do we consider that Dr. Johnson’s 
“concession,” in which he related the standard of care in 
 
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Virginia to the standard elsewhere, had any effect upon the 
presumption.  Once the plaintiff established that Dr. 
Johnson met the educational and examination requirements 
for licensure in Virginia and, therefore, was entitled to 
the statutory presumption that he knew the Virginia 
standard of care for cardiothoracic surgeons, the burden 
shifted to the defendants to show Dr. Johnson was wrong in 
his premise that the Virginia standard and the standard 
elsewhere are the same.  To carry this burden, the 
defendants were required to show that the Virginia standard 
differs from the standard elsewhere.  See Griffett v. Ryan, 
247 Va. 465, 473, 443 S.E.2d 149, 154 (1994).  Yet, the 
defendants produced not a scintilla of evidence on the 
point, and the presumption remained intact.    
We do not overlook the rule that “the question whether 
an expert is qualified rests largely within the sound 
discretion of the trial court,” Henning v. Thomas, 235 Va. 
at 186, 366 S.E.2d at 112, or the maxim that “[a] decision 
to exclude a proffered expert opinion will be reversed on 
appeal only when it appears clearly that the witness was 
qualified.”  Noll v. Rahal, 219 Va. 795, 800, 250 S.E.2d 
741, 744 (1979).  But, in light of the defendants’ failure 
to overcome the presumption provided by Code § 8.01-581. 
20, it appears clearly that Dr. Johnson was qualified.  
 
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Accordingly, it was error for the trial court to exclude 
his testimony. 
The defendants argue, however, that the plaintiff “has 
utterly failed to demonstrate reversible error.”  Their 
argument is two fold.  First, they say that the plaintiff 
“includes in his Brief of Appellant no discussion of the 
testimony he hoped to elicit from Dr. Johnson” and, thus, 
has given this Court “no basis to evaluate the prejudice he 
now . . . avers he suffered when the trial court excluded 
Dr. Johnson from testifying on the standard of care 
applicable to the defendant doctors.”   
Second, the defendants say that the plaintiff 
“obtained the standard of care testimony he sought from Dr. 
Johnson from another expert witness, Dr. [Alfred Joseph] 
Martin, [Jr.],” and the plaintiff fails to explain “how the 
exclusion of Dr. Johnson prejudiced him . . . in light of 
his success in eliciting the same category of evidence 
sufficient to get his case to the jury.” 
We disagree with the defendants.  In the following 
passage from his Brief of Appellant, the plaintiff refutes 
the first prong of the defendants’ argument by providing 
this basis to evaluate the prejudice he avers he suffered 
when the trial court excluded Dr. Johnson’s testimony: 
 
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The Court’s ruling excluding the testimony of Dr. 
Johnson clearly prejudiced the plaintiff, Fred Black.  
He made an appropriate proffer setting forth what Dr. 
Johnson’s testimony against each of the defendants 
would have been had he been permitted to give it. . . 
.  More importantly, Dr. Johnson was not only 
qualified to testify as to the Virginia standard of 
care, he is a world authority whose accomplishments 
have been accorded international recognition and is 
the father of the operative procedure out of which 
this suit arose.  His testimony would have carried 
great weight with the jury.  Counsel in opening 
statements informed the jury of who Dr. Johnson was 
and expressed great pride in the fact that he was 
going to testify on the behalf of the plaintiff.  When 
the court refused to let him testify, Fred Black and 
his counsel . . . lost credibility with the jury.  
 
In the following passage from his reply brief, the 
plaintiff answers the second prong of the defendants’ 
argument by providing this explanation of how the exclusion 
of Dr. Johnson’s testimony prejudiced him despite his 
ability to get his case to the jury with Dr. Martin’s 
testimony: 
 Dr. Johnson is a world authority on 
cardiovascular surgery, which is the same specialty as 
the defendants in this case. . . . Dr. Martin . . . is 
from a different specialty, vascular surgery, and 
while he was qualified as being from a related field, 
he could certainly by no stretch of the imagination be 
claimed to be a world authority.  While much of what 
he testified to was similar to the proffer that was 
made for Dr. Johnson, no argument can genuinely be 
made that his testimony carried as much weight as Dr. 
Johnson’s would have.    
 
For the error in excluding Dr. Johnson’s testimony, 
the judgment of the trial court will be reversed and the 
 
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case remanded for a new trial in which the doctor’s 
testimony shall be allowed. 
Reversed and remanded. 
 
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