### IN THE COURT OF APP EALS OF TENNESS EE AT NAS HVILLE May 6, 200 8 S es sio n
MELI SSA MI CHEL LE COX v . M. A. PRIMARY AND 

### URGENT CARE CLI NIC, ET AL 

### . Appeal f rom the Circ uit Court for Rutherford Coun ty No. 51941 Royce Taylor, Jud ge

No. M2007- 01840-COA-R 3-CV - F iled Janu ary 30, 2009

Plaintiff in medical malpra ctice a ction appea ls the trial court’s g rant of summar y judgme nt in favor of def endant doc tor and c linic. The trial cour t fo u n d t h at the deposition testimony of Plaintiff’s expert witness failed to esta blish ge nuine issues of mater ial fac t with respe ct t o the re quirements of Tenn. Code Ann. § 29- 26-115(a ). F inding e rr o r, we r ever se and r emand the c ase f or fur ther proce eding s.
Te nn. R . A pp. P . 3 App e al a s o f Rig ht ; J udgm e ntof t he Ci r c uitCo ur t R e ve r se d

R I C HAR D H. D I NK I NS , J ., delivere d the opi nion of t he court, in which P ATR I C I A J. C O T T RE LL , P.J ., M.S., and ANDY D. B E NN E TT , J ., joined.

Wi ll ia m K e n n e r ly

B ur g e r , M ur f

r e e s b o r o , T e n n e s s e e , f

o r th e a p p e ll an t, M e li s s a

M ic h e ll e Co x.
J ohn R. Rucker, Jr., Murfre esboro, Te nn es s ee , for the a ppellee, M.A . Primary

and Ur g ent Care Clin ic a nd Au sti n A dams.
OP IN ION

Melissa Cox (“Ms. Cox”) broug ht suit ag ainst Dr. Austin Adams (“D r. Adams”) and M.A

. Primary and Ur g ent Care Clini c (the “Clinic”) f or medica l malpr ac t i ce p u rsuant to t he provisions of Tenn. Code Ann. § 29-26-115. Ms. Cox allege d that Dr. Ada ms w as the Medica l Direc tor of the Clini c; that it was staff

ed by Michae l Maddox , phy sician’s a ssistant; and that Dr. Adams a nd the Clini c fa iled to pr omptly and completely evaluate and treat he r sy mptoms over a two month period. As a c onsequenc e, she as serted, he r ca rdiomy opathy

went undiagnosed, ca

using he r unwa

rra nted pain and suff

ering , the worse ning of

her c ondition and resulting sur g ery

. Ms. Cox conte nd e d that she ha d mai nta ine d a phy sic ian/p a tie nt re latio ns hip wi th t he Clin ic since Septembe r 2003 and that, beg inning in Apr il 2004, she sought consultation and tre atment for prog ressive r espirator

y problems. She had sever al appointments over the months of Apr il, May and-2-

June ; a ll o f h e r a

pp oi nt men ts were han dle d b y Mr . M a dd ox. O n Jun e 19 , w hil e on va c a tio n in F lor ida , s he so ug ht m e dic a l atte nti on fo r a c ute sh or

tness of brea th at

a ho sp ita l e me rg e nc y

ro om. Upon re turning to Tennesse e, s he wa s treate d at Stonecre st Medical Center in Smy rna, where she was diagnose d with a severe form of cong estive heart failure, as a result of which she had a mitra l valve r eplac ement on Jul y 15, 2004.

Dr

. Ad ams and the Clin ic fi le d a mot ion fo r s umm ary

jud g me nt, su

pp or te d b y the a ff ida vit s of Mr. M ad d o x an d Dr. Ada ms and a stateme nt of undisputed fac ts. The af fidavits stated that neither D r. Adams nor t he C linic violated the standa rd of c are and that Ms. Cox did not suffer a ny injury as a r esult of any

action or omission on their par t. The motion also co n t en d ed that the complaint did not alleg e what act or omission of either the C linic or Dr. Adams failed to meet the standard of

car e or the date on whic h the ac ts or omissions occur red.

Ms. Cox’ r esponse to the motion re lied upon excerpts from her deposition, the deposition of her e x pert, Dr . Nelson Mang ione, and her response to the statement of undisputed fa cts. In the brief , in support of her r esponse to the motion, Ms. C ox stated the followingwith respec t to her cla im and the state of the rec ord for purposes of the court’s c onsideration of the summary judgme nt motion:
. . . [T] he Af

fidavits [filed by

Def endants in support of the motion] do not specific ally

addre ss the require ments of the above -desc ribed statute [Tenn. C ode Ann. § 6 3 -1 9 -1 06], i ncluding the written protoc ol of the diag nosis in question. Specifica lly , the Aff

idavits do not re fute Ms. Cox’s c ontention that D r. Adams wa s entirely absent fr om her progressively debilitating c are during

th e th r e e mo nth s wh ich pr e c e de d h e r a c ute e pis od e at Sto ne Cr e st M e dic a l Ce nte r i n late -Jun e , 20 04. M s. Cox descr ibes in detail her ina bility to c ommunicate with D r. Adams; his g ener al and
e va siv e re sp on se s to he r c omp la int s in a si ngle tele ph on e c a ll; and the c e rt a in conclusion that her

entire evaluation and treatment, from April of 2004 through J une o f 2 0 0 4 , w a s s in g le

- h an d e d ly c o n d u c te d b y Phy s ic ia n ’ s A s s is ta

n t M ic h a e l M a d d o x, rathe r than Dr . Adams. The sta ndard of car e in that reg ard is statutorily define d, and is not refuted in the A ffidavits submitt ed in support of the Motion for Summary J udg ment. Asid e from the statutorily descr ibed standar d descr ibed, Dr. Ma ng ione (a s a bo ard -c e rt if

ie d int e rn a l me dic ine do c tor and c ard iol og ist ) p os se sse s e xpe rt ise and experienc e which r ender s him competent to provide testi m o n y rega rdingthe defa ult in the standard of c are by Dr. Ada ms and his Phy sician’s Assistant. The motion was g rante d by the trial cour

t. I n g ranting summary judgme nt, the court found that Dr

. M an g io n e w a s n o t a b le to te s ti f

y a s to th e s ta

n d ar d o f c ar e a p p li c a b le to p h y s ic ian’s
a ssi sta nts and , c on se qu e ntl y , c ou ld n ot e sta bli shthat D r. Ad ams a

nd /or the Clin ic fa ile d to a c t in
a c c o r d an c e w it

h th e s ta n d ar d

. T h e c o urt a ls o f

o un d th a t th e r e w a s n o p r o o f in th e r e c o r d th a t any deviation from the a

pplicable standa

rd of c are was proximately cause d b y Dr

. Adams’ a ctions or omissions . Finally , the cour t found that the deposit ion of Dr. Mang ione di d not meet the standa rd established in Tenn. Code Ann. § 29-26-115( a).-3-

Ms. Cox filed a moti o n to rec onsider, citingtestimony of Dr. Ma

ng ione which ha d been overlooke d, n o t ci t ed o r taken out of c ontext by the trial cour

t in ruling on the motion. The c ourt
overr uled the motion to alter or a mend, stating in part: “The court stated that the issues which the pla int if f b e lie ve d th e c ourt

sh ou ld c on sid e r w e re matte rs that sh ou ld b e a dd re ssed by an a pp e llate court.” This appea l ensued.

Ms. Cox art ic ulate s th e iss ue fo r r e so lut ion a s f oll ow s:
Ba sed upon the wor ding c ontained in T .C.A. § 63-19-106, is there a standard of

car e applicable to phy sician’s a ssista n ts, in medical malprac tice cla ims, which differ s f r o mth e s t an d ar d

o f c ar e a p p l i c a b l e t o th e s u

p e r v i s i n g l i c e n s e d

m e d i c a l d o c t o r ?

Dr . A dams a

nd the Clin ic art ic ulate the iss ue s thus ly : 1. Did plaintiff, Melissa Michelle Cox, satisfy the re quirements of Te nn. Code Ann. § 29-26-115( a) in orde r to maintain a medic al malpra cti ce l awsuit ag ainst the de fe nd ants ?

2. May the plaintiff asser t a theory of neg lige nce, i.e ., neg lige nt supervision, which theory was not alleg ed in the orig inal complaint.?

I. Stand ard of Review

The issues we re r esolved in the trial c ourt on summary judgme nt. Summ ary

judgme nts do not e njoy a presumption of corr ectne ss on a ppeal. BellSouth Adve r. & Publ’g Co. v. Johnson , 100 S.W. 3d 20 2, 20 5 ( Te nn . 2 00 3) . T his c ourt mus t mak e a fr e sh de te rm inatio n that the re qu ir e me nts of Tenn. R. Ci v. P. 56 have be en satisfied. Hu nte r v . B ro wn , 955 S.W .2d 49, 50-51 (Te nn. 1977). We c on sid e r t

he e vid e nc e in t

he lig ht m os t f

avo ra ble to t he no n- movin g pa

rt y and re so lve a ll infere nces in that party ’s favor. Stovall v. Clarke , 1 13 S.W. 3d 71 5, 72 1 ( Te nn . 2 00 3) ; Godfrey v

. Ru is , 90 S.W .3d 692, 695 (Tenn. 2002) . When review ing the evidenc e, we first deter mine whether fa c tua l di sp ute s exist. I f a fa c tua l di sp ute e xists , w e the n d e te rm ine wh e the r t he fa c t is mate ri a l to the claim or de fense upon which the summary judgme nt is predicate d and whe ther the disputed f act
c r e a te s a g e nu in e is s u e f

o r trial. Byr d v . H

all , 8 47 S.W. 2d

20 8, 21 4 ( Te nn . 1 99 3) ; Rutherford v. Polar Tank Trailer, Inc ., 978 S.W .2d 102, 104 (Tenn. Ct. App. 1998). I f there is a dispute as to any materia l fac t or if there is any doubt as t o the ex istence of a material fac t, summary judgme nt cannot be g rante d. By rd

v . H all , 84 7 S.W. 2d

at 21 0; EV

COCor p. v . R os s , 528 S.W .2d 20, 25 (Tenn. 1975)

. To be e ntitled to sum mary judgme nt, the moving pa rty must affirmatively

neg ate a n essential element of

the non-movingparty ’s claim or show that the nonmoving pa rty cannot pr ove an e ssential
e le me nt o f t

he c la im at tr ia l. Hannan v. Alltel Publ’g Co. , 270 S.W .3d 1, 8-9 (Te nn. 2008).T enn

. Co de Ann. § 29

- 26

- 11 5(a) p ro vid es a s f o l l o w s: 1

I n a ma l pr a c t i c e a c t i on , t h e c l a i ma n t s h a l l h a v e t h e bu r de n of pr ov i n g by e v i de n c e as p rovided i n s ub sect i o n (b): (1) t he reco gni zed s t and ard o f accep t ab l e p rof

ess i o nal practi ce in th e p rof ess i o n and t he special t y t heret o , i f

any , that the d ef

end ant p ract i ces i n t he co m m uni t y i n whi ch t he d ef end ant pr ac t i ce s or i n a s i mi l ar c ommun i t y a t t h e t i me t h e al l eged inj u r y or w r on g f u l a ct i on
occ u r r ed; (2 ) T h a t t h e d e fen d a n t ac te d w ith le ss th a n o r fa iled to a c t with o rd ina ry c a re a n d re a so n a b le care i n acco rdanc e wi t h s uch st and ard; and ( 3) As a pr oxi mat e r es ul t of t he def endan t ’ s ne gl i gen t ac t o r om i s s i on, t he pl ai nt i f f s uf f er ed i nj ur i es wh i ch woul d ot her wi s e n ot ha ve occur r ed

.
T e n n . C o d e A n n . § 6 3 -6 -2 0 4 d e fine s “p ra c tice o f m e d ic ine .” S e c tio n 6 3 -6 -2 0 4 (b ) p ro v id e s in p e rtine n t p a rt: 2

N ot hi ng i n t hi s ch apt er s hal l b e so cons t r ued as t o prohi bi t ser vi ce re nder ed by a phy s i ci an

as s i s t an t , . . . i f

s u ch s er v i ce i s r en der ed u n der t h e s u per v i s i on , c on t r ol a n d r es pon s i bi l i t y of

a li c e n se d p h ysic ia n

. . . .
T h is sta tute a p p lies to the p ro v isio n o f o ste o p a thic se rv ic e re n d e re d b y a p h ysic ia n a ssista n t. 3
-4- II. Discussion

A. The A pplicable Standar d of Care

A threshold conte ntion of Dr. Adams and the Clinic is that Ms. Cox ha s failed to meet the
re qu ir e me nts of

Te nn . Co de Ann. § 2 9- 26 -1 15 (a ) wh ic h r e qu ir e s th a t e a c h o f t he thr e e ba sic 1 elements of a

malprac tice ac tion - the standar d of ca re, br eac h of the standa

rd, and pr ox imate ca

use - b e p r o v e nb y

e xp e rt t e s ti mo ny

. See Payne by Paynev. Caldwell, 796 S.W .2d. 142, 143 (Tenn. 1990). Dr. A dams and the Clinic asser t that Dr. Mang ione’s admission that he d i d n o t know the standard of

car e applica

ble to a phy sician assistant means that he cannot testify to a violation of the standard of car e and, thus, Ms. Cox cannot establish a g enuine issue of materia l fac t as to whether the Clin ic fa ile d to me e t th e sta nd ard of a c c e pta ble pr of e ssi on a l pr a c tic e fo r a

phy sic ian a ssi sta

nt. In response , Ms. Cox contends that Te nn. Code Ann. § 63-19- 106 “sets forth a vicarious standard based upon the supervision rende red by the prim ary car e phy sician.” In essenc e, she c ontends that the phy sician assistant, by virtu e o f § 6 3 -1 9 -1 06, is held to the same standa rd of c are as the supervisingphy sician.

The Te nnessee Phy sician Assistants Act i s codified at Tenn. Code Ann. § 63-19-101, et. seq. Tenn. Code Ann. § 63- 19-102 def ines “phy sician assistant” to be “ an individual who re nders service s, whether

diag nostic or thera

peutic, that ar e ac ts constituti n g t h e prac tice of me dicine . . . and, but for the provisions of § 63-6-204 and § 63-9-113, could only be perf ormed by a license d 2 3 phy sician.” Aphy sician assis t an t is require d to be license d. See Tenn. Code Ann. § 63- 19-105. Pursuant to Tenn. Code Ann. § 63- 19-106, a phy sician assistant may per fo rm s el ected medicalSup ervi si o n requir es “act i ve and co nt i nuo us o vervi ew of t he p hy si ci an ass i st ant ’ s act i vi t i es t o ensur e t hat t he 4 phy s i ci an’ s di r ect i ons an d advi ce are in f ac t im pl ement ed, but does not r equi r e t he cont i nu ous an d cons t ant phy s i cal p re se n c e o f t h e su p e rv ising p h ysic ia n .” T e n n . C o d e A n n . § 6 3 -1 9 -1 0 6 (a )( 1 ).

T hi s i s subst ant i al l y t he same req ui rem ent as set f o rt h at T enn. C o d e A nn. § 6 3

- 1 9

- 1 0 6 (a)( 2 ). 5
-5- service s only

under the supervision of a lice nsed phy sician. The ra ng e of service s to be per formed 4 by the phy sician as s i s t an t “s h all be set for th in a written protocol jointly develope d by

the supervisingphy sician and the phy sician assistant,” id. § (a)(2), a nd the phy sician assistant “may perf orm only those tasks that are within the phy sician assistant’s ra ng e of skills and compe tence , that
are within the usual scope a nd prac tice of the super

vising phy sician, and that are consistent with the protec tion of the hea lth and well-be ing of the patient.” Id. § (a) (3).

In a dd iti on

to t he phy sic ian’ s su

pe rv iso ry fu nc tio n, Se c tio n 6 3- 19 -1 06 (b ) p ro vid e s:
A p h y s i cian a ssistant shall function only under the control and r esponsibility of a lic e ns e d p hy sic ian. Th e su pe rv isi ng phy sic ian h a s c omp le te and a bs olute a uth or ity
over a ny action of the phy sician assistant. Ther e shall , at all times, be a phy sician who is answe rable for the actions of the phy sician assist ant and who has the duty of assuringthat there is proper supe rvision and control of the phy sician assistant and that the assistant’s ac tiviti es ar e other wise appr opriate.

Cha pte r 0 88 0- 3 o f t

he Rul e s and

Re g ulatio ns of

the Te nn e sse e B oa

rd of Me dic a l E xami ne rs , titled “Gene ral Rules and Regulations Governingthe Prac tice of a Phy sician Assi stant,” re quires that the servic es per formed by the phy sician assistant “must form a usual component of the supervising phy sician’s scope of pra ctice,” Rule 0880-3-.02, a nd that there be a written protocol deve loped jointly betwee n the supervisin g p h y s i cian a nd the phy sician assistant outlining the se rvice s to be perf ormed by the phy sician assistant. Rul e 0880-3-.10. Chapter 0880- 2-.18, g overningthe 5 supervision of phy sician assistants, provides in per t i n ent part that the protocols “shall outline and
cover the applica

ble standar d of care,” Rule 0880-2-.18(5) (b), a nd that the supervisingphy sician

“ sh a ll b e re sp on sib le fo r e ns ur ing c omp lia nc e wi th the a

pp lic a ble sta nd ard of c are un de r (5 ). ” Rul e 0880-2-.18( 5).

Dr . M ang ion e te sti fi e d a s to the sta nd ard of c are , a s f oll ow s: Q. The opinions t hat y ou have e x presse d today are based upon your kn ow le dg e , e xpe ri e nc e and tr a ini nga s a

c ard iol og ist ; is that c or

re c t? A. Cor re c t. Q. In all fairne ss, Doctor, you’re expressing o pinions of standard of car e inv olv inga

pr ima ry c are phy sic ian a

nd a PA; is that c or

re c t. A. Say ag ain, now. Q. Yes, sir. D o y ou know the s t an d ard of car e applica ble to a phy sician assistant in Middle Tennessee ?-6- A. Iwo uld

a ssume th at th e stan da

rd of c are of a phy sic ian a ssi sta

nt w ou ld be the standa

rd of c are of a pr imary

car e provide r. Q. Do you know t he st andar d of care applicable to a primary car e phy sician i nM i d d l e T e n n e s s e e , R

u th e r f o r d C o un ty? A. I believe so. Q. Ho w i s it

that you kn owthat if

y ou ’v e ne ve r p ra c tic e d th a t? A. I f I ’ve ne ver pr actice d as a pr imary car e phy sician? Q. Yes, sir. A. Th e dia g no sis of

a c on dit ion

– a pr ima ry c are phy sic ian’ s r e sp on sib ili ty to diag nose a condition is the same re sponsibili ty of an e merg ency

room phy sician and the pr imary

car e phy sician as we ll. T h e p ri m ary car e phy sician made the diag nosis in thi s case

. We d isa g re e wi th t

he tr ia l c ourt

and fi nd that D r. Mang ion e ’s te sti mony was su ff ic ie nt t o comply with T enn. Code Ann. § 29- 26-115(a ) (1). Pursuant to statute a nd applicable regulations, the service s provided by

a phy sician assistant ar e provided under the supervision of a licensed phy sician and within the scope of pra ctice of that phy sician, who is responsible for the t reatment rende red by the phy sician assistant. Consequently , the standard of car e applicable to a phy sician assistant is that of the super

vising phy sician in the community in which the super

vising phy sician pra ctices.

B. The Summary

J udg ment Motion The summary

judgme nt analy sis ha s been clar ified in two rec ent opinions by the Tenne ssee Supreme Court. See Martin v. Norfolk Southern Railway Co. , No. E2006-01021- SC-R11-CV, 2008 WL49 22 43 4,
__

_ S. W.3 d _

__ (T e nn . N ov . 1 4, 20 08 ); Hannan v. Alltel Publ’g Co. , 270 S.W .3d 1 (Tenn. 2008) . A par

ty is entitled to summary judgme nt only if the "pleading s, depositions, answers to interrog atories, a

nd admissions on file, toge ther with the aff idavits . . . show that there is no g enuine issue a s to any

materia l fac t and that the moving party is entitled to a judgme nt as a matter of law. " Te nn . R. Civ . P. 56 .0 4; ac c or d P enley v. Honda M

otor Co. , 31 S.W .3d 181, 183 (Tenn. 2000). The movingparty has the ultimate burden of persua ding the court that ther e ar e no g enuine issues of mater ial fac t and that the moving party is entitled to judgment as a matter of la

w. Byrd v. Ha ll , 847 S.W .2d 208, 215 (Tenn. 1993) . Acc ording ly , a properly supported motion for summary jud g me nt m

us t sh owtha

t th ere a re no g e nu ine iss ue s o f m ate ri a l f a c t and that th e mov ingpa

rt y is entitled to judgment a s a matter of law. See Staples v . CBL & Assocs., Inc

. , 15 S.W .3d 83, 88 (Tenn. 20 00 ); McCarley

v. W . Quality Food Serv. , 9 60 S.W. 2d 58 5, 58 8 ( Te nn . 1 99 8) . T he mov ingpa rt y may make the re qu ir e d s ho wi ngand the re fo re sh if

t th e burd e n o f p ro du c tio n to the no nmo vin g pa rt y by either: (1) aff

irmatively

neg ating an esse ntial element of the nonmoving pa rty ’s claim; or (2) sh ow ingtha

t the no nmo vin g pa

rt y c ann ot pr ov e an ess e nti a l ele me nt of the c la im at tr ia l. Hannan
v. Alltel Publ’g Co. , 2 70 S.W. 3d 1, 8- 9 ( Te nn . 2 00 8) ; see also Mc Carley , 960 S.W. 2d a t 58 8; By rd , 847 S.W .2d at 215 n.5. I f t he movi ng party makes a proper ly supported mot ion, then the nonmoving party is require d t o p ro duce e vidence of spec ific fa cts establishing that g enuine issues of material fac t exi st. McCarley , 96 0 S.W. 2d at 5 88 ; By rd , 847 S.W .2d at 215. The nonmovingparty may s a t i s f y i t s b ur d e no f

p r o d u c t i o nb y:A ltho u g h M r. M a d d o x sta te s tha t his inv o lve m e n t with M s. C o x w a s d u rin g the ye a rs 2 0 0 3 a n d 2 0 0 4 , his 6 af f i d avi t ref

ers t o t he “ m ed i cal care whi ch I prov id e d to M el i ss a C o x i n 20 0 2 and 20 0 3 " as i n co m p l i ance wit h t he sta n d a rd o f ca re

. -7- (1) pointing to evidence establishing material fa ctual disputes that wer e over -looked or ig nored by

the moving pa

rty ; (2) re habilitating the ev idence attacke d by the moving pa

rty ; (3 ) produc ing a dditional evidence establishing the exis tence of a g enuine issue f

or trial; or (4) submitting a n aff idavit expl aining the nec essity for further discovery

pursuant to Tenn. R. Civ. P., Rul e 56.06. McCarley , 9 60 S.W. 2d

at 58 8; ac c or

d B y rd , 847 S.W .2d at 215 n.6. Ap ply ing thi s ana ly

tic a l fr ame wo rk

to t his c a se , in

or de r t o s hif

t th e burd e n o f p ro du c tio n to Ms. Cox , Dr. Ada

ms and the Clinic were require d to either a ffirmatively neg ate a n essential ele ment of Ms. Cox ’ cla im or show that she could not prove an essential element of her claim at trial. I f they
ma de thi s r e qu ir e d s ho wi ng , th e n M s. Cox w a s re qu ir ed to pr od uc e e vid e nc e of

sp e c if ic fa c ts establishing that ge nuine issues of mater ial fac t exi st.

In support of their motion for summary jud gm en t , Dr. Ada

ms and the Clinic filed the
a ff ida vit s o f D r. Ad ams a

nd Mr

. Ma dd ox. B oth se t fo rt h the his tor

y of the ir inv olv e me nt w ithMs. Cox and stated t h at t h e car e provide d her “ complied with the re cog nized standard of pr ofessional practice of a

phy sician assistant pra cticingin Rutherford County , Tenne ssee.” In addition, Dr. 6 Adams’ a ffidavit states that his super vision of Mr. Maddox “complied with the recog nized standard of ac cepta

ble profe ssional prac tice of a phy sician ser

ving in the positi o n o f s up ervisingphy sician or a phy sician assistant” and that the professional service s he re ndere d Ms. Cox “complied with the
rec og nized standa

rd of acc eptable profe ssional pr actice of a phy sician prac ticing famil y m edicine and a phy sician ser

ving a s supervising phy sician of a phy sician assistant.”

Th e a ff ida vit s o f D r. Ad ams a

nd Mr . M a dd ox ne g a te d a

n e sse nti a l e le me nt o f M s Co x’ c la im,
v i z. , t h at they

failed to re nder se rvice s in acc ordanc e with the applica ble standar d of ca

re, the reby shifting the bur den to her to come for

war d with proof to establish a tria ble issue of fa ct.

Dr. Mang ione provided the following testimony providing specific s of Mr. Maddox’ failure to comply with the standard of

car e: Q. T h e w ay

y o up h r a s e d

it e ar li e r is h e f a il e d to p e r f o r m t h e n e c e s sary diag nostic studies in order to make the diag nosis in a timely fashion. A. Cor re c t. Q. I s there any

thing else that y ou fee l Mr. Maddox di d that failed to mee t the standard of

car e? A. No. * * * Q. What in y ou opinion was it that Mr. Maddox di d not diag nose?-8- A. He did not diag nose pulmonary edema

. Q. I s there a

ny thing else in your opinion that Mr. Ma ddox failed to diagnose? A. B ecaus e he fa ile d to re c og nize pu lmo na ry e de ma , h e fa ile d to dia g no se c ard iomy op athy . A nd

be c a us e he fa ile d to dia g no se c ardi om y op a thy , h e fa ile d to d i a g n o s e m i tr a l i n s u f

f i c i e n c y.
We find that this testi mony is sufficient to establish a g enuine issue of materia l f

act r elative to the require ment of Tenn. Code Ann. § 29-26-115( a)( 2) and that, conseque ntly , Ms. Cox met her bur den to p ro du c e e vid e nc e of

sp e c if ic fa c ts e sta

bli sh ingthat g e nu ine iss ue s o f m a te ri a l f a c t e xist.

Th e tr ia l c ourt a lso he ld that the re wa s no pro of that Ms . Co x suf

fe re d in jur ie s a s a pr oximate
r e s u lt o f th e p h y s ic ia

n ’ s n e g li g e n t a c t o r o mi s s io n w h ic h w o u ld n o t h av e o th e r w is e o c c ur

r e d

. We have r eviewe d the testimony of Dr. Ma

ng ione and note the followingtestimony which is sufficie nt to c re a te a

g e nu ine iss ue of

mate ri a l f

a c t on the c a us a tio n r e qu ir e me nt: Q. What injury or dama g e or c onsequenc e did Ms. Cox have be cause of the
e xiste nc e of

the mitra l va lve de fe c t? A. Th e pr ob le m wi th mitra l va lve ins uf fi c ie nc y is that th e he art

mus c le – if mitral insufficienc y is c aught e arly enoug h and the pr oblem is surg ically corr ecte d, the n th e de ve lop me nt o f c ard iomy op a thy c an b e a bo rt e d. So b y

not maki ngthi s diag nosis quickly , she develope d a car diomy opathy that resulted in other
c omp lic atio ns

. Q. What ot

he r c omp lic a tio ns ? A. Well, she has subsequently require d a PACE maker

implanted – a devic e imp lantatio n f

or her c ardi om y op a thy , a

nd he r p ro g no sis ha s b e e n a lte re d a s a c o n s e qu e n c e o f

th e d e v e l o p m e n to f

th e c ar d i o m yo p a th y. C. Neg lige nt Supervision

Dr. Ada ms and the Clinic contend that Ms. Cox raises o n ap p eal a theory of re cover

y , Dr. Adams’ ne g lige nt supervision of Mr. Maddox, which was not a lleg ed in he r complaint. In light of our disposition of this appea l, we make no deter minat ion as to the appropr iateness or viability of such cla im.

III. Conclusi on The judg ment of the trial c ourt dismissi ng this case is re verse d and the c ase is re manded f or further proce eding s in acc ordanc e with this Opinion.-9-

C o s t s ar e a s s e s s e d

t o M

. A

. P r i m ar

y C ar e an d U r g e n t C ar e C l i n i c an d A u s t i nA d am s , e qu a l l y, for whic h execution may

issue, if nec essar

y
.

___________________________________

RI CHARD H. DI

NKI NS, J UDGE