### IN THE COURT OF APP EALS OF TENNESS EE AT JAC KSON Ma y 20, 200 9 S es sio n
SAMANTHA NABORS v. W IL LI AM M. ADAMS, M. D., ET AL 

### .
Direc t Appeal from the Circ uit Court for Sh elby County No. CT-000369-07 John R. Mc Carr oll, Jr., Judge

No. W2008-02418-C OA-R3-C V - F iled Jul y 23, 2009

Th is a pp e a l in vo lve s a

me dic a l mal pra c tic e a c tio n. I n a mot ion fo r s umm ary

jud g me nt, defe ndant phy sician asse rted that plainti ff’ s expert witness failed to satisfy the re quirements of the loc a lity ru le . T he tr ia l c ourt

g ra nte d th e mot ion fi nd ing that pla int if f’ s e xpe rt fa ile d to d e mon str a te a fa miliarity with the standard of

car e in def

endant’s community

or a similar c ommunity . I n a motion to alter or amend the judgme nt, pla intiff attache d a supplemental aff idavit of the same e x pert in order to c ure the defic iency . The trial c ourt consider ed the e x p ert’s suppleme ntal aff idavit and de nie d th e mot ion

be c a us e the ne w a ff

ida vit sti ll f a ile d to satis fy the loc a lity ru le . Pl a int if

f a pp e a ls. Reviewing the re cord, w e find that the e x pert’s suppleme ntal aff idavit c ured the initial deficienc y by relating f acts whic h showed the similarity of the two communities. Accor dingly , we r ever se the judgme nt of the trial cour t.

Tenn. R. App . P . 3 Appeal as of Right; Judgme nt of th e Circ uit Court Reve rsed and Rem anded

J. S TEVE N S T A FF O RD , J ., delivere d the opinion of the cour t, in which A L AN E. H I G H ERS , P.J ., W.S ., and H OL L Y M. K I RBY , J ., joined.

Da nie l M. Cza mans ke , Jr. , Cl ark sd a le , M iss iss ipp i, f or the Ap pe lla

nt, Samanth a

Na bo rs

. Te re sa J. Sig mon , K a the ri ne M. An de rs on , Jon a tha n W. Mc Cr ary , M e mph is, TN , f or the Ap pe lle e s, Wil liam M. Adams, M.D. and The Clini c for Plastic and Reconstruc tive Surg ery , P.A.

OP IN ION

Bac kgr ound-2-

Appellant Samantha N abors wa s a patient of D r. Will iam Ad a ms , a p la s tic surg eon pra cticing in M e mph is, Te nn e sse e . O n F e br ua ry 13 , 2 00 6, Dr

. Ad a ms pe rf or me d la bia pla sty surg e ry on

Ms. Nabor s. A labiaplasty

is elec tive surg ery for the r eduction and a esthetic improveme nt of the labia. After the surg ery , Ms. Nabors wa s dissatisfied with the results.

To reme dy

the damag e, Ms. Nabor s visited Dr. J ohn Miklos, a doctor pra cticing in Atlanta, G e o r g ia w it h a spec ialty

in urolog ical g y

necolog y . Dr. Miklos subsequently perf ormed two surg erie s to rec onstruct t he labia. T he surg erie s, howeve r, could not re pair the da mag e complete ly

beca use, as Dr. Miklos noted, Dr . Adams esse ntially remove d the entire labia minor.

On Janu ary 23 , 2 00 7, Ms. Na

bo rs (“ Pla int if

f” ) f ile d a c omp la int

a g a ins t D r. Na

bo rs and his
e mpl oy e r, Th e Clin ic of

Pla sti c and

Re c on str uc tiv e Sur g e ry , P. A. (“ De fe nd ants ” ), in S he lby County Circuit Court. The complaint alleg ed that Dr. Adams’s malprac tice during the la biaplasty surg ery cause d signific ant phy sical and me ntal harm to Plaintiff. Def endants answere d and filed a motion fo r s umm ary

jud g me nt. Th e mot ion

a sse rt e d th a t summa

ry jud g me nt w a s a

pp ro priate be c a

us e Plaintiff c ould not establish her cause of action with c ompetent expert proof. A r uling on the motion was postponed until Plaintiff could prepa re he r expert witness, Dr. Miklos.

Plaintiff then filed the a ffidavit of D r. Miklos. I n the af fidavit, Dr. Miklos stated that he w as fa mil iar w iththe sta

nd ard of me dic a l c are fo r t his pr oc e dure in b oth

At lanta , G e or g ia

and Me mph is, Te nn e sse e . H e c on c lud e d th a t th e labi a re du c tio n p ro c e dure pe rf or me d b y Dr . A dams w a s in vio la tio n o f t

hat sta nd ard of c are

. Af

te r takin g Dr

. Mik los ’s de po sit ion , De fe nd ants re ne we d th e ir mot ion fo r s umm ary

jud g me nt a sse rt ingth at Dr. Mik los wa s n ot a c omp e te nt e xpe rt . In s up po rt , Def endants pointed to the followingpassag e in his deposition:
Q : Is t h e r e a

n a t i o n a l s t an d ar d

o f c ar e f o r t h e p e r f o r m an c e o f l a b i a p l a s t y? A: I just never hear d it put that way , national s tandar d of ca re. I didn’t know there
w a s a b i g d i s c r e p an c y. Q: We ll , w o u ld y o u te s ti f y d if f e r e n tl y a b o u t th e s ta

n d ar d o f c ar e in F lo r id a f or the perf ormanc e of a

labiaplasty

than in Memphis, Tennesse e? A: Ican’ t imagine Iwould, but, y ou know, I ’m just try ing to make sure that Idon’t–I j u s tu n d er s t an d

wh at y o u ’r e s ay i n g. Q : D o yo ukn o w

–t e l l m e w h a tyo ukn o w a b o u tt h e M e mp h i s m e d i c a l c o m m u n i t y? A: No t h i n g. Q: Ha ve y ou e ve r b e e n to any

ho sp ita ls i n M e mph is? A: No. Q: Do y ou

kn owany

pla sti c surg e on s in

Me mph is? A: No. Q: Do y ou

kn owho w m any

ob -g y ns or ur og y ne c olo g ist s th e re are in M e mph is?-3-

A: No. Q: Do y ou

kn owany

ur ogy ne c olo g ist s in

Me mph is? A: Ye s. Q: Who do y ou know? A: Ibelieve V al Vog t is there
*** Q: Do y ou

kn ow , D oc tor , a

ny pla sti c and

re c on str uc tive su rge on s in

Me mph is, Tenne ssee? A: Not that I ’m awa

re of

. Q: Do y ou know how many colleg es there are in Memphis, Tennessee ? A: No. Q: How many

hospitals there a

re? A: No. Q: How many

hospitals are the re in Atlanta ? A: Idon’t know. Q: How many

colleg es ar e ther e in Atlanta? A: Idon’t know. Q: How many

urog y necolog ists are ther e in the Atlanta a rea ? A: Any body who wants to ca ll themselves one. Q: Do y ou know any

t h i n g at all, Doctor, a

bout the service s or spec ialities that are available in Memphis, Tennessee ? A: No.

Plaintiff did not file a written re sponse to Def endants’ motion.

On June 24 , 20 08 , the tr ia l c ourt e nte re d a n o rd e r s tr iki ngDr . M ikl os a s a n e xpe rt wi tne ss and g ra nti ngsu mma

ry jud g me nt t o th e De fe nd ants

. In this or de r, the tr ia l c ourt art ic ulate d th e ba sis fo r i ts c on c lus ion

a s f oll ow s:

I t appea rs t o the court that Dr. Miklos prac tices only in the Atlanta, Ge org ia ar ea a nd is not li cense d and has ne ver prac t i ced in Tennessee or in the Memphis are a. Dr

. Miklos has never be en to any of the hospitals in Memphis and is wholly unfamiliar with the Memphis me dical community and the service s and resour ces available here

. He wa s una

ble to a rt ic ulate any fa c tua l ba sis wh a tso e ve r ind ic a tin g that th e At lanta
are a in which he prac tices and t h e M e mp his medical communities are simil ar me dical communities. I n fac t, he admitted that he know s nothing a bout the Memphis medical community

or the re source s and ser

vices available here

. Dr. Miklos, ther efor e, is not qu a lif ie d a s an e xpe rt

un de r t he Te nn e sse e me dical ma lpr a c tic e “ loc a lity ” ru le in Tenne ssee Code Annotated 29-26-115 and he is, theref ore, stric ken as a

n expert for plaintiff.

Wit hin thirty

day s of the filing of this order, Plaintiff f iled a motion to alter or amend the summary judgme nt pursuant to Tenn. R. Civ. P. 59.04.-4-

Th e mot ion

to a lte r o r a

me nd inc lud e d th e su

pp le me nta l a ff

ida vit of Dr. Mik los . In th is
a ff ida vit , D r. Miklo s r e c ite d f a c ts a bo ut t he me dic a l c omm

un iti e s ( e .g ., numbe r o f h os pit a ls, estimated population) of A tlanta, Geor g ia and Me mphis, Tennessee . Wit h this new information, Dr. Miklos conclude d that Memphis and Atlanta wer e si milar communities with reg ard to the standa rd of car e for a labiaplasty

. The trial court considere d the information provided in th e s u p p l em ental aff idavit but found that Dr. Mikl os still did not qualify as an expert under the loc ality rule. Plaintiff then filed a

timely notice of a

ppeal.

Law a nd A nal ys is Summary judgme nt is a

ppropriate when the moving pa rty can show that there is no ge nuine issue of m ater ial fac t and that it is entitled to a judgme nt as a matter of law. Te nn. R. Civ. P . 56.04; Hann an v. Allt

el Publ’g Co. , 2 70 S.W. 3d 1, 5 ( Te nn . 2 00 8) ; B

y r d v . H all , 847 S.W .2d 208, 214 (Tenn. 1993) . When consideringa summary judgme nt motion, t he cour t must review the e vidence in the light most favor able to the non-moving party and dra w all re asonable infere nces in its favor

. Staples v

. CBL & Assocs., Inc. , 15 S.W.3 d 83, 89 (T e nn . 200 0)

. B e c a us e su mma

ry jud g me nt o nly involves questions of law, our r eview of the trial cour

t’s ruling is de novo with no presumption of
corr ectne ss. Martin v. Norfolk S. Ry. Co. , 271 S.W .3d 76, 84 (Tenn. 2008)

. We r eview a trial court’s ruling on a motion to alter or amend a judgme nt under Te nn. R. Civ. P. 59.04 only

for a n abuse of

discretion. Stovall v. Clarke , 113 S. W

. 3 d 7 1 5 , 7 2 1 (Tenn. 2003) ; Li nko us v . L ane , 276 S.W .3d 917, 924 (Tenn. Ct. App. 2 0 0 8). A trial c ourt abuses its discre tion
on ly wh e n it ha s “ a pp lie d a n in c or re c t le g a l st andard , o r r e a c he d a de c isi on wh ic h is a g a ins t lo g ic
or rea soning that cause d an injustice to the par ty complaining .” He nry

v . G oin s , 104 S.W .3d 475, 479 (Tenn. 2003)

. A. Sum m ar y J udgm e nt

I n an action for medical malprac tice, the claimant has the burden of pr o v i n g “[ t] he
rec og nized standard of a cce ptable prof essional pra ctice in the pr ofession and the spec ialty there of, if any , that the defendant practice s in the community in which the def

endant pr actice s or in a similar community

at the time the alleg ed injury or wrong ful ac tion occurr ed.” T enn. Code Ann. § 29-26- 115(a) (1). This e lement of the pla intiff’s ca use of a ction is known as the “loc ality rule.” Sto v all , 113 S.W .3d at 722. L ike t he other elements of medical malpr actice , a plaintiff must demonstrate the
re cog nized standard of c are in the community with expert proof. N

o r r is v . Ea s t T e nn essee Chi ldren’s Hosp. , 195 S.W .3d 78, 86 (Tenn. Ct. App. 2005). The plaintiff’ s expert must t here fore “have knowledg e of the standard of profe ssional car e in t h e def endant’ s applicable community or kn o w l e d g e o f

t h e s t a n d a r d o f p r o f

e s s i o n a l c ar e i na

c o m m u n i t y that is show n to be similar to the defe ndant’s community .” Sto v all , 1 1 3 S

. W

. 3 d at 7 2 2 (q u o t i n g Robin son v . LeCorps , 83 S.W .3d 718, 724 (Tenn. 2002)

.-5-

I n order t o s at i s fy

the locality

rule, a n expert may

discuss a national standa rd of c are but “such e vidence may

not substit ute for e vidence that first establishes t he requirements of Tenn. Code Ann. § 29-26-115( a)( 1).” Sto v all , 113 S.W .3d at 722. I n Robin son , the Court found that the e x pert wi tne ss f a ile d to “ re la te the ba sis fo r his kn ow le dg e of the sta nd ard of c are in Na sh vil le or ind ic a te why the Nashville medic al community was similar t o, and thus had the same standar d of prof essional
car e as the community

wit h wh i ch [ t h e ex pert] was familiar.” Robin son , 8 3 S

. W

. 3 d a t7 2 5

. In Sto v all , on the other ha

nd, the expert witness “e x presse d understandingof the local i t y rul e and
e xpla ine d th a t he ha d applie d th e loc a lity sta nd ard of c are -a nd no t a natio na l st and ard -t o th e fa c ts and cir cumstance s in this case.” Sto v all , 113 S.W .3d at 723.

I n the pre sent case , Dr. Mikl os indicated in his deposition that he wa s completely unawa re of the standa

rd of c are for this proce dure in Memphis, Tenne ssee. Instead, he applied a na tional standard of

car e base d on his ex perie nce in Geor g ia. On appea l, Plaintiff first asser ts that the expert te sti mony is s uf fi c ie nt b e c a

us e Dr . M ikl os is f

a mil iar w iththe pr oc edu re u se d b y Dr . A dams. B e c a us e Dr . M ikl os ha s p e rf

or me d th e same pr oc e dure , Pl a int if f a rgue s th a t he c an te sti fy

a s to whether Dr. Adams perf

ormed it pr operly

. This a rg ument, howeve r, ig nores the f irst require ment of Tenn. Code Ann. § 29-26-115( a)( 1), which de mands familiarity with either de fenda

nt’s
c omm un ity or a sim ila r c omm un ity . M ere fam ili ari ty

wi th t he re le va nt p ro c e dure is i ns uf

fi c ie nt. Ac c or din g ly , w e fi nd

tha t th e tr ia l c ourt

pr op e rl y e xclu de d D r. Mik los a s Pla int if f’ s e xpe rt wi tne ss at the summary

judgme nt stag e.

B. R ule 59 .0 4 M ot ion to Al te r or Am e nd

Plaintiff also contends that the tria l court er red w hen it de nied her motion to alter or ame nd the judg ment. Plaintiff supported her Rule 59.04 motion with additional evidenc e; spec ifically , she attache d the supplemental a ffidavit of D r. Miklos. I n this affidavit, Dr. M i k l o s ci ted re fer ence materia ls to demonstrate that the Memphis and A tlanta medica l communities were similar. B ased on this new information, Dr. Miklos conclude d that the t wo communi ties had the same standard of
car e for this particular sur g ery

. Plaintiff argues t hat this affidavit satisfies the require ments of Tenn. Code Ann. § 29-26- 115.

The Te nnessee Supreme Court, in Sto v all , s ta te d th a t “ [w] hen additio na l e vid e nc e is pr e se nte d in

su pp or t of a [Rule 59 .0 4]mo tio n, the tr ia l c ourt sh ou ld c on sid e r the fa c tor s a pp lic a ble to a motion to re vise a partial summary judgme nt pur suant to Rule 54.02 of the Tenne ssee Rules of Ci v il Pr o c e d

u r e[.] ” S tov all , 1 13 S.W. 3d a t 72 1. I n c on sid e ri ngsu c h a mot ion , tr ia l c ourt s sh ou ld there fore apply

the following “non-e x clusive bala ncing test”: 1) the movant' s eff

orts to obtain evi d en ce to r espond to the motion for summary judgme nt; 2) the importance of t he newly submitt ed evide nce to the mova nt's c ase; 3) the e x planation offe red by the movant for its fa ilure to offe r the ne wly submitt ed evidenc e in its init ial response to the motion for summary judgme nt; 4) the likelihood that the nonmoving pa

rty will suf fe r u n fair prejudice ; and 5) a ny other re levant fac tor.-6-

Har ris v . Che rn , 33 S.W. 3d

74 1, 74 5 ( Te nn . 2 00 0) . Wh e n a pp lyingthi s te st, tr ia l c ourt s “ sh ou ld make adequate finding s of fact and conclusions of lawon the re cord to support their r ulings.” Id

. As noted above , we r eview the trial court’ s ruling o n a Rule 59.04 motion onl y for a n abuse of discretion. Id . at 74 6; se eals o , Sto v all , 1 13 S.W. 3d a t 72 1; Kenyon v. Handal , 122 S.W .3d 743, 766 (Tenn. Ct. App. 2003) (re viewing a trial court’s a pplication of the Har

ris fac tors to a Rule 59.04 motion for an abuse of discre tion).

I n Kenyon , the c ourt e xpla ine d that “ re lie f un de r Te nn

. R. Civ

. P. 59 .0 4 is a vail abl e on ly when the supple mental af fidavit eff

ectively reme dies the def

ects or shor

tcomi n gs i n t he ea

rlier aff idavit opposing the phy sician' s summary judgme nt motion.” Kenyon , 122 S.W .3d at 765. The t ri al co u rtm ay

co n s i d er “[ w] h et h er

a n ew or sup p l em en t al af

fi d av i tef fe ct i v el y re b u t s t h e d ef

en d an t 's aff idavit” under

the fifth Har

ris fac t o r which allows consideration of “any other re levant fa ctor.” Kenyon , 1 2 2 S

. W

. 3 d

at 7 6 5 n

. 2 3 (c i t i n g Har

ris , 33 S.W .3d at 745). The court then c oncluded that “if a patient files a motion for Tenn. R. Civ. P. 59.04 r elief r elying on a new a ffidavit that itself does not satisfy

the re quirements of...Te nn. Code Ann.§ 29-26-115, the trial court may decline to se t aside its previous summary

judgme nt order.” Kenyon , 122 S.W .3d at 765.

Her e, the tria l court dec ided to consider the information i n cl uded in Dr. Miklos’s
su pp le me nta l a ff

ida vit

. Th e re c or d do e s no t inc lud e any fi nd ing s o f f a c t or c on c lus ion s o f l aw w ith reg ard to the f

our spec ific Har

ris fac tors. I n its final order, t he court only found that “D r. Miklos still does not qualify

under the locality rule and that his supplemental affidavit does not cur e that.” I t theref ore a ppear s that the trial co u rt ’s ruling was ba sed solely on its conclusion that the supplemental af

fidavit did not satisfy

the locality

rule. When the trial court g rante d su mmary judgme nt in favor of

Dr. Ada ms, it found that Dr. M i k l o s f a i l e d t o d e m o n s t r a t e t h a t t h e A t l an t a c o m m u n i t y w a s s i m i l ar t o t h e M e mp h i s c o m m u n i t y. The trial c ourt did not find, and Dr. A dams has not ar g ued, that Dr . Mi k l o s i s unfamiliar with the standard of

car e for this medical proce dure in Atlanta . The que stion, then, is whether Dr . Miklos’s supplemental af

fidavit sufficie ntly

demonstrates that the two communities are s imilar. See Robin son , 83 S.W .3d at 724.

Plaintiff’s burden w as to show w h y t h e M emphis medical c ommunity was similar to, and thus had the same sta

ndard of profe ssional car e as the comm u nity (her e, Atlanta) with which Dr. Miklos was familiar. See Sto v all , 113 S.W .3d at 723. To m eet this burden, “ a plaintiff' s expert can establish that a communit y with which he or she is familiar is similar to that of the one in whic h the defe ndant pra ctices based on a compar ison of information such as the siz e, location, and pr esenc e o f te a c h in g h o s p it a ls in th e tw o c o mmunities.” Tr avi s v . Fe rra ra c c io , No. M2003-00916-COA- R3-CV, 2005 WL 2277589, at *11 (Te nn. Ct. App. Sept. 19, 2005) . Howeve r, “[g]ener alizations reg ardingthe similarity of the standa rd s of prof

essional ca

re in two c ontiguous states ar e not spec ific enoug h informa t i o n to demonstrate that a medical pr actitioner is qualifie d under the locality rule to rende r an opinion in a medical malprac tice case.” Jo hnso n v . P ra tt , No. W2003-02110-COA-R3-CV, 2005 WL1364636, at *8 (Te nn. Ct. App. J une 9, 2005).-7-

Her e, Dr . Miklos’s supplemental aff idavit rec ites specific information s howing the simil arities betwe en the Atlanta and Memphis communities. I n this affidavit, he lists the size of eac h city ’s population, the number of institutions of highe r lea rning , and the number

of hospitals in eac h
c ity . H e a lso no te s th a t th e re is a le ve l on e tr a

uma c e nte r an d ana c c re dit e d me dic a l c e nte r i n b oth Memphis and Atlanta. In short, he re lies on the informati o n re co m m ended in Trav is fo r h is compar ison; he does not rely on the g ener alizations rejected in Pratt . We find that t he trial c ourt
err ed whe n it determined that the suppleme ntal affi d av i t failed to satisfy the locality

rule. Consequently , the trial cour t er re d i n d en y ing Plaintiff’ s motion t o alter or amend the summar

y jud g me nt g ra

nte d to De fe nd ants

. The jud g me n t o f th e tr ia l c o u rt is r e v e r s e d an d th is c a s e is r e ma n d e d to th e tr ia l c ourt for fu rt he r p ro c e e din g s. Cos ts o f a pp e a l are a sse sse d to App e lle e s Dr . William Adams a nd Th e Clin ic for Plastic and Rec onstructive Surg ery , P.A., for which e x ecution shall issue if nec essar y

.



### ____ ____ ____ ____ ____ ____ ____ ____ ___ J. S T E V E N S T A FF O RD , J.