Title: Tashman v. Gibbs

State: virginia

Issuer: Virginia Supreme Court

Document:

PRESENT:  All the Justices 
 
HUNTER S. TASHMAN, M.D. 
 
v.  Record No. 010028   OPINION BY JUSTICE BARBARA MILANO KEENAN 
 
 
                         January 11, 2002 
MARGARET GIBBS 
 
FROM THE CIRCUIT COURT OF FAIRFAX COUNTY 
Dennis J. Smith, Judge 
 
 
In this appeal of a judgment in favor of a plaintiff in a 
medical malpractice action, we consider whether the trial court 
erred in permitting the plaintiff's "informed consent" claim to 
be considered by the jury. 
 
We state the evidence in the light most favorable to the 
plaintiff, Margaret L. Gibbs, the prevailing party in the trial 
court.  City of Bedford v. Zimmerman, 262 Va. 81, 83, 547 S.E.2d 
211, 212 (2001).  The evidence showed that Gibbs had received 
obstetrical and gynecological care from the defendant, Hunter S. 
Tashman, M.D., over a period of several years.  Dr. Tashman had 
delivered both of Gibbs' children and had successfully performed 
bladder suspension surgery on her.  After the delivery of her 
second child, Gibbs developed a severe uterine and vaginal 
prolapse, a condition in which the uterus collapses and 
protrudes through the vagina. 
 
In August 1996, Dr. Tashman examined Gibbs and advised her 
that she needed a total hysterectomy and a sacrospinous ligament 
suspension procedure (sacrospinous procedure) to correct the 
prolapse.  In a sacrospinous procedure, the prolapsed vagina is 
pulled back into position and secured with sutures fixed to the 
sacrospinous ligament. 
 
In October 1996, Dr. Tashman performed a total hysterectomy 
and a sacrospinous procedure on Gibbs.  When Gibbs awoke from 
surgery, she experienced severe pain that radiated from her 
right hip, through her right leg, and into her foot.  Gibbs 
could not straighten her right leg or place any weight on it, 
and she experienced numbness in her vaginal area. 
 
The next day, Dr. Tashman examined Gibbs and informed her 
that her pain might have "something to do with the sciatic 
nerve."  After consulting with a neurologist, Dr. Tashman 
concluded that the sutures made during the sacrospinous 
procedure needed to be removed.  Three days after the initial 
operation, Dr. Tashman performed a second surgery to remove the 
sutures. 
 
After the second surgery, Gibbs was able to straighten her 
right leg and to stand upright.  Although her level of pain was 
reduced, Gibbs still experienced "a great deal of pain."  She 
ultimately was diagnosed with permanent injury to her sciatic 
and pudendal nerves.  As a result of these nerve injuries, Gibbs 
has experienced recurring medical problems, including permanent 
pain and a burning sensation in her right leg and hip, numbness 
 
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and loss of sensation in her right foot, and a loss of sexual 
function due to permanent genital numbness. 
 
Gibbs filed a motion for judgment against Dr. Tashman, 
alleging that he was negligent in the manner in which he 
performed the sacrospinous procedure and in failing to obtain 
her "informed consent" to that procedure.  Gibbs alleged that 
Dr. Tashman failed to obtain her "informed consent" because he 
did not tell her that he lacked experience in performing the 
sacrospinous procedure, and did not advise her of the nature and 
risks of the operation, including the risk of nerve damage. 
 
During trial of the case, Gibbs presented the expert 
testimony of Hilary J. Cholhan, M.D., a gynecologist and 
obstetrician who is an associate professor at the University of 
Rochester.  When asked to define the term "informed consent," 
Dr. Cholhan stated: 
[I]nformed consent is not just a piece of paper, it's 
a process, and it's a process of educating the patient 
so that the patient understands what conditions she 
has been diagnosed with and what treatment options are 
available to her, be they non-surgical or surgical.  
So it's not a piece of paper, it's essentially helping 
the patient understand his or her own condition so 
that she can make an informed consent based on the 
ability to determine what the advantages and 
disadvantages are of each treatment, and then the 
patient decides what he or she feels is appropriate as 
treatment. 
 
Immediately thereafter, counsel for Gibbs asked Dr. Cholhan 
whether he had "an opinion to a reasonable degree of medical 
 
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certainty as to what [the] standard of care [in] Virginia 
required in 1996 regarding informed consent."  Dr. Cholhan 
replied, "That, I answered." 
 
Dr. Cholhan stated that there were different surgical 
alternatives available to correct Gibbs' condition.  He referred 
to the sacrospinous procedure performed on Gibbs as the 
"transvaginal approach."  In an alternative procedure, a sacral 
colpopexy, which is often referred to as the "abdominal 
approach," the surgeon makes an incision through the abdomen and 
uses the lower part of the spine in the back of the abdominal 
cavity as an anchoring point to support the vagina. 
 
Dr. Cholhan testified that Dr. Tashman deviated from the 
standard of care when he failed to inform Gibbs of the 
"abdominal approach" as an alternative to the sacrospinous 
procedure.  Dr. Cholhan stated: 
[T]he standard of care requires that all alternatives 
be discussed, and the abdominal approach was not 
discussed.  Now, if Dr. Tashman – if it's not within 
his surgical armamentarium to do that, then you need 
to explain that to the patient, that is not within my 
armamentarium, other people favor doing it this way, 
however, I do not do it this way for these reasons.  
That was not discussed. 
 
Dr. Cholhan defined "armamentarium" as "nothing more than 
repertoire, within the operator's skill and experience and 
knowledge." 
 
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When asked whether he had an opinion within a reasonable 
degree of medical certainty whether Dr. Tashman breached the 
standard of care with respect to obtaining Gibbs' "informed 
consent," Dr. Cholhan replied: 
[W]ith all the information that I have reviewed and 
that's been provided me, including Dr. Tashman's 
notes, I saw no evidence that any patient counseling 
occurred with respect to alternatives of treatment, 
advantages of one treatment over another, 
disadvantages, risk factors, or the like. 
 
However, during cross-examination, Dr. Cholhan agreed that Dr. 
Tashman's only "shortcoming" concerning obtaining Gibbs' 
"informed consent" was his failure to explain to her the 
alternatives to the sacrospinous procedure.  When asked whether 
the "abdominal approach" involved less potential risk than the 
"transvaginal approach," Dr. Cholhan responded that "[e]very 
procedure has inherent risks." 
 
Gibbs testified that Dr. Tashman failed to inform her 
before the surgery that he had never performed a sacrospinous 
procedure as a "lead surgeon," and that she would not have 
consented to having him perform the surgery if she had been 
aware of his limited experience.  Gibbs further testified that 
Dr. Tashman did not inform her of the possible risk of nerve 
damage from the sacrospinous procedure.  According to Gibbs, Dr. 
Tashman only told her that the procedure could result in some 
blood loss and in vaginal dryness.  With regard to blood loss, 
 
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Gibbs also stated that Dr. Tashman assured her that "we won't 
need" the two pints of blood that he instructed her to "bank." 
 
At the conclusion of Gibbs' evidence, Dr. Tashman moved to 
strike the "informed consent" claim from the negligence action, 
arguing that the claim was not supported by sufficient evidence.  
The trial court denied the motion. 
 
Dr. Tashman testified concerning his experience with the 
sacrospinous procedure.  He stated that he had performed two 
sacrospinous procedures under the guidance of more experienced 
surgeons.  He explained that on one of these occasions, he 
served as the "lead surgeon" and performed about 90 percent of 
the surgery.  Dr. Tashman further stated that although the 
operation on Gibbs was the first time he performed the 
sacrospinous procedure by himself, he had the proper training 
and skills to perform the procedure. 
 
Dr. Tashman testified that he informed Gibbs of his 
experience with the sacrospinous procedure and presented her 
with three options concerning who would perform her surgery.  He 
told her that he could refer her to a more experienced surgeon 
to perform the surgery, that he could perform the operation 
himself with the assistance of a more experienced surgeon, or 
that he could perform the procedure "solo for the first time."  
Dr. Tashman stated that Gibbs said that she preferred that he 
 
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perform the surgery by himself because she was uncomfortable 
having "another surgeon in the room that she hasn't met yet." 
 
Dr. Tashman also testified that he thought that "it crossed 
[his] mind to mention" to Gibbs the "abdominal approach" as an 
alternative surgical procedure, but he was unable to recall with 
certainty whether he had discussed this option with Gibbs.  
However, he stated that the "abdominal approach" would not have 
been appropriate for Gibbs because of a greater long-term risk 
of complications presented by that procedure. 
 
Dr. Tashman also stated that he had informed Gibbs of the 
potential risks and complications of the sacrospinous procedure, 
including the risk of nerve damage.  He testified that when he 
advised Gibbs and her husband of these facts, Gibbs acknowledged 
that she understood that the procedure would involve an 
additional level of risk. 
 
Gibbs' husband, Raymond Dennis Gibbs, was called as a 
witness by Dr. Tashman, and testified that when he and his wife 
met with Dr. Tashman to discuss the surgery, "Dr. Tashman did 
not say anything at all about risk of injury to nerves in this 
procedure."  Mr. Gibbs also testified that when he asked Dr. 
Tashman about the risks involved in the surgery, Dr. Tashman 
replied that the sacrospinous procedure was more complicated 
than the hysterectomy because, among other things, the surgical 
area contains "a lot of nerves."  Mr. Gibbs stated that it was 
 
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his understanding that Dr. Tashman "was just explaining the 
procedure" when he made mention of this fact. 
 
Dr. Tashman presented the expert testimony of Fred 
Mecklenburg, M.D., an obstetrician and gynecologist who is a 
clinical professor at George Washington University.  Dr. 
Mecklenburg testified that Dr. Tashman's overall evaluation, 
care, and treatment of Gibbs complied with the applicable 
standard of care.  Dr. Mecklenburg also concluded, based on his 
review of Dr. Tashman's office notes, that Dr. Tashman had 
conducted an "informed consent session" with Gibbs in which the 
surgery and its risks and complications were discussed. 
 
Dr. Mecklenburg testified that the applicable standard of 
care did not require Dr. Tashman to discuss the "abdominal 
approach" with Gibbs.  Dr. Mecklenburg stated that "[t]he most 
appropriate approach to [Gibbs'] particular set of circumstances 
is vaginal.  Not only is the abdominal approach more difficult 
and more complicated, but [it] is less likely to result in 
correction of all of [Gibbs'] problems." 
 
Dr. Mecklenburg testified that Dr. Tashman was "adequately 
prepared" to perform the sacrospinous procedure.  Dr. 
Mecklenburg also stated that for someone with Dr. Tashman's 
experience in performing pelvic surgery, training for this 
particular procedure is merely a matter of familiarizing the 
 
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surgeon with the proper location and manner of suture placement, 
and that "[i]t comes down to the equation of see one, do one." 
 
At the conclusion of this evidence, the trial court denied 
Dr. Tashman's renewed motion to strike Gibbs' "informed consent" 
claim.  The jury returned a general verdict in favor of Gibbs in 
the amount of $4,000,000.  Pursuant to Code § 8.01-581.15, the 
trial court reduced the jury's award to $1,000,000, and the 
court entered judgment on the verdict.  Dr. Tashman appeals from 
this judgment, challenging the trial court's decision to allow 
the jury to consider Gibbs' "informed consent" claim.  However, 
Dr. Tashman does not assign error regarding the sufficiency of 
the evidence of Gibbs' other claim that he was negligent in his 
performance of the sacrospinous procedure. 
 
Dr. Tashman argues that the evidence was insufficient as a 
matter of law to support Gibbs' "informed consent" claim, 
including the nature and extent of his duty of disclosure, and 
whether any alleged breach of this duty was a proximate cause of 
Gibbs' injuries.  He emphasizes that Gibbs' expert, Dr. Cholhan, 
did not identify the risks related to the sacrospinous procedure 
that a reasonably prudent obstetrician and gynecologist was 
required by the standard of care to disclose.  Dr. Tashman 
further contends that Dr. Cholhan did not testify that the duty 
to obtain a patient's "informed consent" requires a physician to 
disclose to the patient the extent of his experience in 
 
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performing a particular procedure.  Finally, Dr. Tashman argues 
that while Dr. Cholhan's testimony may have established a breach 
of the standard of care in Dr. Tashman's failure to inform Gibbs 
of the "abdominal approach," there was no evidence that this 
omission proximately caused Gibbs' injuries. 
 
In response, Gibbs asserts that the evidence was sufficient 
to establish that Dr. Tashman failed to obtain her "informed 
consent" because he did not disclose the risks of the 
sacrospinous procedure or advise her of any appropriate 
alternative procedures.  Gibbs also argues that the evidence was 
sufficient to establish that in obtaining a patient's "informed 
consent," a physician is required to disclose to his patient the 
extent of his experience in performing a proposed procedure.  
She contends that Dr. Cholhan's testimony supports this 
conclusion because he stated that a physician must disclose to 
his patient whether a certain procedure or skill is within his 
armamentarium.  We disagree with Gibbs' arguments. 
 
A physician has a duty in the exercise of ordinary care to 
inform a patient of the dangers of, possible negative 
consequences of, and alternatives to a proposed medical 
treatment or procedure.  See Rizzo v. Schiller, 248 Va. 155, 
158, 445 S.E.2d 153, 155 (1994).  To recover against a physician 
for failure to provide such information, the patient generally 
is required to establish by expert testimony whether and to what 
 
10
extent any information should have been disclosed.  Moates v. 
Hyslop, 253 Va. 45, 48, 480 S.E.2d 109, 111 (1997); Rizzo, 248 
Va. at 159, 445 S.E.2d at 155; Bly v. Rhoads, 216 Va. 645, 650-
51, 222 S.E.2d 783, 787 (1976). 
A physician's duty of disclosure is defined with reference 
to the appropriate standard of care.  See Dickerson v. Fatehi, 
253 Va. 324, 327, 484 S.E.2d 880, 881 (1997); Rogers v. Marrow, 
243 Va. 162, 167, 413 S.E.2d 344, 346 (1992); Raines v. Lutz, 
231 Va. 110, 113, 341 S.E.2d 194, 196 (1986).  We have defined 
the standard of care in a medical malpractice action as that 
degree of skill and diligence exercised by a reasonably prudent 
practitioner in the same field of practice or specialty in 
Virginia.  Bryan v. Burt, 254 Va. 28, 34, 486 S.E.2d 536, 539 
(1997); Pierce v. Caday, 244 Va. 285, 291, 422 S.E.2d 371, 374 
(1992); Raines, 231 Va. at 113, 341 S.E.2d at 196. 
A physician's deviation from the applicable standard of 
care must generally be established by expert testimony.  
Dickerson, 253 Va. at 327, 484 S.E.2d at 881; Rogers, 243 Va. at 
167, 413 S.E.2d at 346; Raines, 231 Va. at 113, 341 S.E.2d at 
196.  Once a plaintiff has met the burden of establishing the 
standard of care and a deviation from that standard, she may 
establish by lay testimony that her physician did not disclose 
certain information regarding risks, and that she had no 
knowledge of those risks.  Bly, 216 Va. at 649-50, 222 S.E.2d at 
 
11
787.  As in other negligence actions, the plaintiff also must 
prove that the physician's negligent omissions were a proximate 
cause of the injury sustained.  Bryan, 254 Va. at 34, 486 S.E.2d 
at 539-40; King v. Sowers, 252 Va. 71, 76, 471 S.E.2d 481, 484 
(1996); Brown v. Koulizakis, 229 Va. 524, 532, 331 S.E.2d 440, 
446 (1985). 
In the present case, Gibbs' "informed consent" claim was 
based on three subjects that Dr. Tashman allegedly failed to 
disclose to her prior to the surgery.  Those subjects were: 1) 
the risks of the sacrospinous procedure, including the risk of 
nerve damage; 2) Dr. Tashman's limited experience in performing 
the procedure; and 3) the available alternatives to the 
sacrospinous procedure. 
On the issue of risks, we conclude that Gibbs failed to 
establish by expert testimony that the standard of care in 1996 
for an obstetrician and gynecologist in Virginia required 
disclosure of any particular risks of the sacrospinous 
procedure, including the risk of nerve damage.  Dr. Cholhan 
failed to identify any risks of the procedure that a reasonably 
prudent obstetrician and gynecologist was required to disclose 
to a patient contemplating such surgery.  Instead, he merely 
stated that nerve damage is a risk of the procedure, and that he 
saw no evidence in the medical records that Dr. Tashman provided 
any patient counseling regarding risk factors. 
 
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Gibbs' contends, nevertheless, that Dr. Tashman's own 
testimony established the appropriate standard of care when he 
stated that he had advised Gibbs of certain risk factors, 
including the risk of nerve damage, that might result from the 
sacrospinous procedure.  We disagree.  This evidence from Dr. 
Tashman did not address the standard of care for disclosure of 
risks, but merely addressed the factual issue whether he made 
any disclosures to Gibbs. 
Gibbs next contends, in the alternative, that she was not 
required to present expert testimony regarding the standard of 
care and Dr. Tashman's deviation from that standard because he 
did not advise her of any risks of the sacrospinous procedure.  
We do not reach the merits of this argument, however, because 
Gibbs' factual premise is incorrect.  Gibbs testified that Dr. 
Tashman advised her that the surgery could result in blood loss, 
although it was unlikely, and in vaginal dryness.  Thus, because 
Dr. Tashman advised Gibbs of certain risks of the sacrospinous 
procedure and Gibbs failed to present expert testimony 
establishing what the standard of care required regarding 
disclosure of risks, Gibbs' proof on this issue was insufficient 
as a matter of law. 
 
On the issue of Dr. Tashman's experience, we conclude that 
Gibbs failed to establish by expert testimony that the 
appropriate standard of care in 1996 for an obstetrician and 
 
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gynecologist in Virginia required Dr. Tashman to disclose to 
Gibbs the extent of his experience in performing sacrospinous 
procedures.  Dr. Cholhan did not state that the standard of care 
required a reasonably prudent obstetrician and gynecologist to 
disclose the extent of his prior experience in performing a 
particular surgery.  Instead, in his discussion of the 
"abdominal approach," Dr. Cholhan stated that if Dr. Tashman did 
not have the skill and experience to perform that procedure, he 
was required to disclose this fact to his patient. 
This testimony did not establish a standard of care 
requiring a physician to disclose his prior experience in 
performing a particular procedure, but addressed only the 
disclosure required by a physician who lacks the skill and 
experience to perform a particular procedure.  Here, however, 
there was no testimony that Dr. Tashman lacked the skill or 
experience to perform a sacrospinous procedure.  Dr. Mecklenberg 
testified that Dr. Tashman was "adequately prepared" to perform 
the procedure, based on his experience in performing pelvic 
surgery and his prior knowledge of the procedure.  In addition, 
Dr. Tashman stated that he had the proper skill and experience 
to perform the sacrospinous procedure.  Thus, we conclude that 
the evidence was insufficient as a matter of law to support this 
component of Gibbs' "informed consent" claim. 
 
14
 
We next consider the third subject of Gibbs' "informed 
consent" claim, that Dr. Tashman failed to disclose the 
available alternatives to the sacrospinous procedure.  Dr. 
Cholhan testified that the standard of care required Dr. Tashman 
to discuss the "abdominal approach" surgical alternative with 
Gibbs, and that Dr. Tashman failed to do so.  In addition, Dr. 
Tashman was unable to recall whether he discussed this surgical 
option with Gibbs.  This testimony, viewed in the light most 
favorable to Gibbs, established a standard of care requiring 
such disclosure and Dr. Tashman's deviation from that standard 
of care. 
 
There is no evidence in the record, however, that this 
deviation from the standard of care was a proximate cause of 
Gibbs' injuries.  In a medical malpractice action, a plaintiff 
must establish not only that a defendant violated the applicable 
standard of care, and therefore was negligent, but must also 
prove that the negligent act was a proximate cause of her 
injury.  Bryan, 254 Va. at 34, 486 S.E.2d at 539-40; King, 252 
Va. at 76, 471 S.E.2d at 484.  A proximate cause of an event is 
an act or omission that, in a natural and continuing sequence, 
produces the event, and without which the event would not have 
occurred.  Sugarland Run Homeowners Ass'n v. Halfmann, 260 Va. 
366, 372, 535 S.E.2d 469, 472 (2000); Atkinson v. Scheer, 256 
 
15
Va. 448, 454, 508 S.E.2d 68, 71 (1998); Beale v. Jones, 210 Va. 
519, 522, 171 S.E.2d 851, 853 (1970). 
Here, Gibbs did not state that she would have decided 
against having the sacrospinous procedure if Dr. Tashman had 
informed her of the "abdominal approach" alternative.  Instead, 
she stated that she would not have allowed Dr. Tashman to 
perform the sacrospinous procedure if she had known of his 
limited experience in performing that procedure.  Thus, we 
conclude that Gibbs' evidence on this component of her "informed 
consent" claim was insufficient as a matter of law, because this 
evidence did not establish that Dr. Tashman's failure to inform 
her of the "abdominal approach" affected her decision to have 
him perform the sacrospinous procedure. 
Because Gibbs' evidence regarding all three components of 
her "informed consent" claim was insufficient as a matter of law 
to raise a jury issue, we conclude that the trial court erred in 
submitting that part of her malpractice action to the jury.  
Based on the trial court's error, Dr. Tashman argues that the 
entire negligence action must be remanded for a new trial.  We 
agree. 
We cannot determine from the record whether the jury based 
its verdict on the issue of "informed consent" or on the issue 
of Dr. Tashman's alleged negligent performance of the 
sacrospinous procedure.  Therefore, we cannot say that the 
 
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evidence and instructions erroneously submitted to the jury on 
the issue of "informed consent" did not affect its 
determination, and we must presume that the jury relied on such 
evidence and instructions in reaching its verdict.  See 
Ponirakis v. Choi, 262 Va. 119, 126, 546 S.E.2d 707, 711-12 
(2001); Rosen v. Greifenberger, 257 Va. 373, 381, 513 S.E.2d 
861, 865 (1999). 
For these reasons, we will reverse the trial court's 
judgment and remand the case for a new trial on both counts of 
Gibbs' motion for judgment. 
Reversed and remanded. 
 
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