### TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

NO. 03

- 20

- 00394

- CV

Aveen B. Zachariah, D.O. , and Austin Regional Clinic, P.A. , Appellant s

v. Alfred J. Durtschi, Individually and as Executor o f the E state of Doris A. Liesenfelt, Deceased , Appellee

FROM THE 419TH DISTRICT COURT OF TRAVIS COUNTY NO. D

- 1

- GN

- 19

- 00523 , THE HONORABLE AMY CLARK MEACHUM , JUDGE PRESIDING

M E M O R A N D U M O P I N I O N

In this medical malpractice case, Aveen B. Zachariah, D.O. , and Austin Regional Clinic, P.A. , ap p eal from the trial court ’ s interloc utory order overruling their objections to
Dr. Juan C. Salgado ’ s amended expert report and denying their moti o n to di s miss and request for
attorney ’ s fees

. See Tex . Civ. Prac. & Rem. Code §§ 51.014(a)(9) (authorizing ap p e al from interlocutory o rder denying relief sought un der section 74.351(b) of Texas Me dical Liability Act (TM LA)), 74.35 1 (b) ( generally requiring dismis sal of heath care liability c laim on motion of
d efendant physician or health care provider when cla iman t fails to co m ply with threshold expert report requirement and requiring trial court to award attorney’s fees and costs when expert report
is not ser ved within statutory deadline ). In two issues , appellan ts ar gue that the trial court abused
its discretion (1) in denying their motion to dismiss becaus e D r. Salgado was not qualified , and
h is opinions were defic ient , and (2) in denying their request for a ttorney ’ s fees and costs

.2 Because we conclud e that the trial cour t did not abuse its discretion in denyin g appellants ’ motion to dismiss and request for attorney ’ s fees and costs , we a ffirm the trial court ’ s order.

BACKGROUND
Alfr ed Durtschi , 1 indiv idually a n d as executor of the estate of D oris A. Liesen f elt,
dece ased , s ued Dr. Zachariah and Austin Regi onal Clinic for health care liability claims arising
from Dr. Zachariah ’s medical ca re of Lie senfelt

. 2 Durtschi alle ge d that Dr. Zachar iah was

ne glig ent in his medi cal care and that Austin Regional Clinic w as vicarious ly liab le for his negligence

. In his peti tion, D urtschi alleged that :

• on June 20 , 2018, Dr. Zachariah re moved an ab s cess from the shoulder of Liesenfelt , who
was “ 64 years o ld and in ver y goo d health ” ; 3

• on July 23 , Lies enf elt returned to Dr

. Zachariah because of “ significant back pain and frequen t urina tion , ” and he pr es cribed “ pain medication and referred her to ph ysical therapy ” ;

• on Jul y 2 7 , Liesenfelt ’ s pain and sym pto ms continued to wo rse n , she presented to a n emergency room , a “ blood c ulture revealed pos i tive findings for multiple st rands of streptococcus, ” and a CT scan of the abdomen and pelvis revealed acute cholecystitis ,

1 Counsel for Alfred Durtschi has not ified this Court that Durtschi has passed away. Despite his death after t he inc eption of this appeal, we use his name ( rather than that of his heirs
or e state) in this opinion. See Tex. R. App. P. 7.1(a)(1) ( pro viding that when party in civil case dies d uring pendency of appeal, app ella t e court proceeds to adjudicate appeal “ a s if all p arti es were alive ” and tha t “ decedent party ’ s na me may be used on all papers ” )

. Further, Durtschi ’ s death doe s not end the controversy between the parties. See Kenseth v. Dallas C o unty , 126 S.W.3d 584 , 593 (Tex. App.

— Dallas 2004, pet. denied) ( explaining that “ if a claim remains that involves th e property rights of the parties, then the claim survives the death of a party ” )

.

2 Durtschi sued other health care providers but nonsuited those claims

.
3 The petition incorrect ly states that the ab s cess removal occurred on July 9, 201 8, but the parties agree that i t occurre d on June 20, 201 8, w hich is t he date that Dr . Salga do also states in his report : “ On 6 /20/18 , . . . Dr. Zac hariah diagnos ed Ms. Lie senfelt with an infectious process to her back a s w ell as had an abscess drained and w as dis charged with a n antib iotic prescription. ”3 “ an inflammation of the gall bladder , typic ally occurri ng whe n a gallstone obstructs the
c ystic duct ” ;

• tha t s a me day, Li e senfelt ’s gall bladder , which was “gan g renous in appearance ” with “a large amount of exudate and f luid around the gallbladder and liver, ” was re moved ;

• following her discharge from the hos pital , Li e senf elt ’s illness cont inued and she began exper i encing “ severe back pain ” and other s ym p toms unt il she was rushed ba ck to the emergency room on August 28 and diagnosed with “ severe sepsis with shock ” ;

• the follow ing day, a n MRI showed “complicate d MSSA bacteremia with extensive epidural abscess , ” whic h required “ surgical asp i r a t ion of the epi dural a b scess to at tempt clearance o f bacteremia ” ;

• “ Li e senfe lt ’s condition worsened followi ng the surgical evaluation, ” and “cultures from [the] epi dural ab sc ess drai nage grew MRSA, despite the fact that her b lood c ultures have been growin g MSSA ” ; and

• a few day s later, Li e se nfelt died of “ septic shock seconda ry t o MRSA in fection with multi

- organ failu re. ”

D urtschi timely serv ed appellants with Dr. Sa lgado ’ s exper t report and curriculum
vitae ( CV)

. See id. § 74. 3 51(a) ( generally requiring claimant to serve e xpert repo rt wit h in 120 th day after defen dant ’ s original answer is filed) , (r) (6) (defining “ expert report ” )

. In his re port,
Dr. Salgado a ddress ed his b ackgr ound and qualification s , listed the medical records that he reviewed, provided a summary of m edica l events, and th e n opined about the st an dard of care for a family care physic ian like Dr. Zachariah, his breach es of the standard of care , and the causal

conn ection between Dr. Zachariah’s breaches of the stan d ard of care and Liesenfelt’s death

. Dr. Salga do op i ned that D r . Zachariah breached the standard of care :
by not ordering a ny radiological testing concurrently with his 6/20/18 abscess removal, by no t ins isting on a prompt follow

- up following the 6/20/18 a bscess removal, and by not ordering any radiol ogical testing f ollowing the 7/23/18 visit despite his knowledge of Ms. Liese nfelt’s infectious process and described tenderness to palpat ion of the lowe r bac k.4 Dr. Sa lg a do al so opined that had Dr. Zachariah conformed with the standard of care, “ the lumb ar
in fection would have in all likelihood been detected e ar lier t han it was ” and “ in all medical probability Ms. Liesenfelt would not hav e ultima tely bec ome g ravely septic (as the lumbar
abscess could have bee n drained or removed prior to sepsis deteriorat ing to the point o f death). ” According to his CV , Dr. Salgado holds active medical licenses and is board
certified in critic al care , internal medicin e , a nd pulmonary disease ; he complet ed postgraduate

prog r ams in internal me dici ne in 2007 and cr itical care medicine in 201 0 ; served on a Sepsis
Committee from 2007 to 200 8 at a medical center; and i n 2008, he pre sente d a lecture or
worksho p on “ Severe Sep s is and Septic Shock

- Updates in Management ” with a “ Fo c u s on Improving Outcomes in the Hospitalized P atient ” and a poster pre sentation “ ‘ Sepsis Guideline Implementation is influenced by physician specialty background , ’ Ma rily n T. Haup t, MD Su rvey

to determine differences in guideline adherence between Internal Medicine, Emergency
Medicine and Critical Car e Me dicine physician s in care of septic patients

. ” His CV also

con firms his experience as the c hief f ello w in c ritical c are m edicine at a medica l ce nter and as
the c hi ef m edical r esident for i nternal m edic ine at a s eparate medical center

. Appellan ts fil ed objections to Dr. Salgado ’ s report and a motion t o di s miss

. A ppellant s challenged Dr . Salgado ’ s qualificatio ns to opine on causation and the stan dard of care for a family care physician and c ontend e d that his opinions on ca usation and the stand ard of c are

were defi cient b e cause they were va gue and conclusor y. F ollowing a hearing, t he trial court signed an order, sustaining one or more of appel lants ’ objections and grant ing Durtschi a 30

- day
extensio n to cure the deficien c y or deficiencies in the exper t r epo rt. See id

. § 74. 351 (c ) (a

uthorizing court to grant one 30

- day extension to cure defi c iency in expert report). Durtschi
ti mely served appel lants with an amen d ed report , and a ppellants filed ob jec t ions to the amended5 report and a second motion to dis miss, gen eral ly clai m ing that the ame nded r eport was deficient

on the same ground s that they raised as to the in itia l report

. D urtschi filed a re sponse and, following a hearing, the trial court signed a n order overruling appellants ’ objections to the

amen ded r e port and den yi ng the ir motion to dismiss

. T his interlocutory appeal follow ed.

ANAL YSIS Chapter 74 Expert Report Requir ement s and Standa rd of R eview Section 74.351 of the TMLA provides a 120

- day window for a claimant who is asserting a health ca re liab ility cla im to s erve each defendant physician and health care provider with an exper t report and the expert ’ s CV. See id. § 74.351(a). “ The purpose of the expert report requirement is to deter frivolous claims , not to dis pose o f cla ims regardless of their
merits. ” Scor esby v. Santillan , 346 S.W.3d 546, 554 (Tex. 2011). Two functions of the expert

rep ort ar e to “ inform the defendant of the specific conduct the plaintiff has called into question ”
and “ provide a basis for the tri al co urt to conclude that the claims have m erit. ” Certified EMS,
Inc. v . Potts , 392 S.W.3d 625, 630 (Tex. 20 13) (quoting Ameri can Tr ansit ional Care Ctrs. of
Tex., Inc. v. Palacios , 4 6 S.W.3d 873, 879 (Tex. 2001)) ; see Baty v. Futrell , 54 3 S.W. 3d 689,
693

– 93 ( T ex. 2018) (describing “ Pala cios f rame w ork ” for reviewing expert rep ort ’ s adequacy )

. A trial court should not grant a mot ion challenging the adequacy of an expert report unless “ it appears to the cour t, af ter hearing, that the repor t does not represent an objective good faith effort to comply with th e definition of an ex p ert repo rt in Subsection (r)(6). ” Tex.
Civ. Prac. & R em. Code § 74.351( l ); see id. § 74.351(r)(6)

. “ A va lid e xpert report has three
elements: it must fairly summar ize th e applicable sta n dard of care; it must explain how a ph ysician or health care provid e r failed to meet that standard; and it must establish the causal6 relationship betw een the failure and the harm alleged. ” Potts , 392 S.W.3d at 630 (citing Tex.
Civ. Prac. & Rem. Code § 74. 351(r)(6)). “ A report that satisfies these requi rements, even if a s to one theory only, entitles the claimant to proceed with a suit against the phys ician or health care

pro vide r
. ” Id. ; see Scoresby , 346 S.W.3d at 549 (holding that “ docu ment qualifies as a n expert report if it contains a sta tement of o pinion by an indiv i dual with expertise indicating that the
claim asserted by the plaintiff against th e defendant has merit ” ). In making its evaluation, “ [ t]he
trial court should look no furt her than the rep ort itself, because all the informatio n relevant t o the inquiry is c o ntained within the document ’ s four corners. ” Bowie Me m ’ l Hosp. v. Wright , 79 S.W.3 d 48, 52 (Tex. 2002) (ci tin g Palacios , 46 S.W.3d at 878) ; see Baty , 543 S.W.3d at 693 ( co nfirm ing that “ r eport ’ s adequacy does not depend on th e use of an y particular ‘ magic words, ’ so long as it contains sufficient information ‘ within the document ’ s four corners ’ to fulfill
Palacio s ’ s two

- part mandate ” (qu oting Bowie Mem ’ l Hosp. , 79 S. W. 3d at 52

– 5 3 ) )

. We r evie w a trial court ’ s d enial of a s ect ion 74.351 motion to dismiss for an abuse
of discretion. Abshire v. Chr istus Healt h Se. Tex. , 563 S.W.3d 219, 223 (Tex. 2018) (pe r
curia m) ; TTHR Lt d. P ’ ship v. Moreno , 401 S. W.3d 41, 44 (Tex. 2 013); Palacios , 46 S.W.3 d at
875. “ Under that standard, appe l late courts defer to the trial court ’ s fact ual determinations if they are supported by evidence, but review its legal determi nations de nov o
. ” Van N ess

v

. ETMC First Physician s , 461 S.W.3d 140, 142 (Tex. 2015). “ A tr ial court abuses its discretion
if it r ule s without reference to guiding rules or principles. ” Id. ; see Hebert v. Hopkin s , 395 S.W.3d 884, 891 (Tex. App.

— Austin 2 013, no pet.) ( expla inin g that court s of appeal d o not
examine conten t of expert repo rt and m ake own de novo determina tion as to wh ethe r ex pert provided sufficient information but de termine whether trial court acte d arbitrarily, unreasonably ,7 and without refe rence to gu i ding rules a nd principles in its det ermination about e xpert report ’ s adequacy )

. With these standards in mind, we tu rn t o app ellants ’ issues.

D id the trial court abuse its discretion in denying appe llants ’ moti on to dismiss ? In their first issue, a pp e llants argue that the tri al court abused i ts discretion in denying their motion t o dismiss because Dr. Salgado ’ s e xpert r eport did no t constitute a good
faith effo rt to comply with t he TMLA ’ s expert r eport requir ements

. In four sub

- issues ,

a

ppellants cha l len ge the adequacy of the report as to causatio n and st andard of care and
Dr. Sal gado ’ s qualification s to render an ex p er t opinion on cau sation and standard of care

.

Caus ation
In their first su b

- issue , appellants a r gue th at the trial co urt abused i t s discretion by impliedly finding th at Dr. Salgado ’ s ex pert report provide d an adequa te summ a ry of the causal
relationshi p between Dr. Za charia h ’ s purported neg ligence and Liesenfelt ’ s injuries and de ath.

“ [C]ausation is established by proof that the negligent act or omission was a
substantial factor in b ringing about the harm and withou t which the harm would not have

o ccurr ed. ” Costello v. Christus Santa Rosa Health Care Corp. , 141 S.W.3d 245, 2 49 (Tex. App.

— San Antonio 2004, no pet.)

. In the conte x t of the T ML A ’ s expert report requirement,

t he eleme nt of causation “ requires th at the e xper t expl ain ‘ ho w a nd why ’ the allege d negligence caused the injury in qu esti on. ” Ab shire , 563 S.W.3d at 224 ( c iting Jelin e k v. C asas , 328 S.W.3d 526 , 536 (Tex. 2010 ) ). “ A conclusory statement of ca usation is inadequate; instead, the expert must explain the basis of his statements and link conclusions to specific facts. ” Id. (citing Jeli n e k , 328 S. W.3d at 539 ) ; see Columbia Valley Healthcare Sys., L.P. v. Zamarripa , 526 S.W.3d 453, 461 (Tex. 2017) ( “ [W]ithout factual exp lanations, the reports are nothin g more8 than th e ip se dixit of th e expe rts, which . . . are clearly insufficient. ” ). “ In satisfying this ‘ how

an d w hy ’ requirement, the expert need not prove the entir e case or account for every known f act; the report is su fficient if it makes ‘ a good

- fait h effo rt to expl ai n, factually, how pr oximate cause is going to be proven. ’ ” Abshire , 5 63 S.W.3d at 224 ( quotin g Z amarripa , 526 S.W.3d at 460 ) ;

see Zamarripa , 526 S.W

. 3d at 460 ( describing proximate cause ’ s two components of foreseeability and cause

- in

- fa ct)

. “ [W]ith resp ect to causati on , t h e court ’ s role is to determine
wh ether the expert has explaine d how the ne gligent conduct c aused the injury. ” Abshire , 563 S.W.3 d at 226

. “ Whether this explanation i s believable shoul d be litigated at a later sta ge o f the proceeding. ” Id. ; see Mil ler v. v. JSC Lake Highlands Operations , L .P. , 536 S.W.3d 510,
516

– 17 (Tex . 2017) (per curiam) ( “ We r emain mindful that an ‘adequate’ expert r eport ‘does not have to meet the same requirement s as the evidence offered in a su mmary - judgment proceedin g

or a t trial. ’” (quoting Scoresby , 346 S.W.3d at 556 n. 60 (quoting Palacios , 46 S.W.3d at 87 9)) )

. In his amended report, Dr. Sal g a do opined that D r. Zacharia h ’ s breaches of the

sta ndard of care

— f ail ing to order radiolog y testing on the lumbar spine and fol lo w - up aft er the
abscess removal

— caused Liesenfelt ’ s death :

The standard of c are requiring a family physi cian to order x - rays or other radiolo gic a l t reatment for patients displaying tenderness on palpation to the back is to reve al the presence of any b ony or soft ti ssue abnormalities. This is particularly importa nt with knowledge of infectious process like t he abscess Dr

. Zachariah removed from Ms

. Liesenfelt’s shoulder on June 20, 2018. The abs cess is an infectious process. D r. Zachariah should have sched uled a p rompt follow

- up following that June 20, 2018 proced ure. If Dr. Zac hariah had or dered a prompt follow

- up visit, Ms. Liesenfelt’s contin u ed back pain should have prompted radiological te sting to ensure the infectious pr ocess (the abscess) had not dissemina t ed to the lumbar spine (which was the location of the infec tion which ulti mately led to her death). F urther, Dr. Z achariah should have ord ered radiological testing on the 7/23/18 visit

. Had Dr. Zachariah conformed wi th these standards of ca re by orderin g radiological testing along with the 6/20/18 abscess removal, recommending an im mediate follow

- up, or ordering radi ological testing9 on t he 7/23/ 18 visit, the lumbar infection would have in all likelihood been detected earlier than it was. Ha d the lumbar i nfection been detected earlier, as it probably would have if Dr. Zachariah had c omplied with the appli cable standar ds of care, in all m e dic al pr obability Ms. L i esenfelt would not have u ltimately become gravely septic ( as the lumbar absces s co uld have been drained or removed prior to sepsis deteriorating to the point of death).
T he fac t that Ms. Liesenfelt tested positi ve for both MRSA and MSS A inf ections does not change the causation res ult outlined above. MRSA stands for methicillin

- resistan t staphylococ c us aureus. MSSA stands for methicillin

sensitive staphylococcus aureus. Both a re the same primary ty pe of bacteri a: staphylococcus. A n M SSA i n fection like the initial positive test f or Ms. Liesenfelt can and does mo rph into MRSA as it evol ves. In this case, in all medical probability, the initial MSSA positive result and the later MRSA positive result can and (with out any contrary fin d ing s in th e records, nor diagnostic testing to re view) probably did share the same origin. That is, in al l likelihood t he bacteria manifesting in Ms. Liesenfelt’s shoulder abscess that Dr. Zach ariah removed had disseminat ed into her l ower spine, morphing fro m MSS A t o MRSA at the time of her death.
In su mmary, Ms. Liesenfelt unfortunate ly succumbed to multi sys tem organ fail ure as a re sult of septic shock from an epidural abscess which s hould ha ve been suspected after the June shou lder abscess removal and J u ly ’ s c linical visit with D r. Zachariah in the set ting of prior soft tissue infecti on and physical findings of localized te nderness.
Appellants argue that Dr. Salgado ’ s “ cau sation op inion i s complet ely conc lusory and impermissible ipse dixit ” ; that his o pinion is internally inconsistent as to foreseeab ility and

cause - in

- fact ; that he n eeded to explain “ how a stap hylococcus in fection can dis seminate generally from the sur face of skin to a di stant loca tion with in the spinal canal or specifically did
so in L iesenfelt ’ s ca se ” ; t hat the report w as “ devoid of any facts to de monstrate that ‘ mo rphing ’

or ‘ dissemination ” [in to MRSA] was foreseeable i n this patient by Dr. Zacharia h ” ; and , relying

on Durtschi ’ s plea ded facts, that Dr. Salg ado failed “ to demonstrat e c ause - in

- fac t , as he doe s no t

ex plain how and wh y this e v olu tion and dissemination o ccurred despite removal of the shoulde r abscess, t reatment with an ti biotics by D r. Zachariah , a 2

- day hospital admiss ion and w orkup for worsening of the same symptoms just d ays after Dr. Zachariah’s la st treatment, conf irm a tion that10 any staph infection was ‘ gone ’ at the end of that hospitaliza tion, and an additional ten days of

‘ strong ’ out

- patient antibiotic therapy aft er d ischa rge from the hospit al. ” 4 Appellants contend

t h at Dr. Salgado ’ s “ causation opinion is not about s epsis ” but “ an anti bi otic

- resist a nt epidural abscess p urportedly caused by a remote, superficial skin in fection, treat able and treated with
antibiotic s ” ; that there were other possibilities for th e origin o f the i nfection of the spine ; and that Dr. Salgad o ’ s report was re q uired to explain “ with medically verifiable evidence t o a reasonable degree of medical probability ” why his in f e r ences and opinions d rawn from those inferences “ are
medic ally preferab le to compet ing inferences eq ually consistent with the known facts

. ” Appellants also fau lt Dr. Salgado for not c iting “ any lit erature or source ” to support his opinions
that “ [ a ] n MSSA i nfect ion like the i niti al positive test for Ms. Liese nfelt can and d oes mo r ph into
MRSA as it evolves ” and that “ a n epidural abscess should have been suspecte d .

. . in the setting of prior soft t issue infe ction and physical findings of local te nderness

. ” Dr. Salgado ’ s a mend ed re p ort , however, s pecifically ad dresse d MRSA and
MSS A , explaining that they are t he sam e type of b acteria , staphylococcus , and n othing in the

stat utory language requires an expert to provide more than a “ fair summary of the expert ’ s opinions , ” such a s requiring the expert to cite litera tu re or some othe r objective source to sup port
his opinions on caus ation

. See Tex. Civ. P rac. & Rem. C ode § 74.351(r) (6) (defining “ exper t

r eport ” to be written report pro viding “ fair summary of the expert ’ s opinions ” ) ; Abshire , 563 S. W.3d at 226 (expla ining that court ’ s r ole is to de termine whether expert ha s explain ed how

4 We disagree with appellants ’ char acteriz ation of Durtschi ’ s pleaded facts, sp ecifically that Dur tschi plea ded that the infection was gone after Liese nfelt ’ s hospital s tay when her gallbladder was removed

. Durtsc hi p leaded t hat when asked if the s taph infection was gone f ollowing the surg ery to remove Liesen felt ’ s gall bladder , a subsequent health car e pro vider

“ spe cifically replied: ‘ yes , but we ’ re going to keep her on strong antibiotics for 10 days

. ’ ” I n o ther words, Durtschi pleade d that a subsequent health care provider told Durtsch i that the infection was gone , not that it was actually gone
.11 negligent conduct c aused injury ; w hether explanation i s bel ie vable is litigated at later sta ge of proceeding ) ; see also New Med. Hor izons, II, Ltd. v. Milner , 575 S.W.3d 53, 70 (Tex. A pp.

— H oust o n [ 1st D i st.] 2019 , no pet.) ( concluding that causation op inion provided “ how and why ”
and a “ straightforward link ” between alleged breach of standard of care and injury ) ; Kelly

v. Rendon , 255 S.W.3d 665, 677 & n.6, 69 9 (Te x
. App.

— Ho uston [14 th Dist.] 2008, no pet

. ) ( explaining that court was not persuaded that s ection 74.351 requires “ type of extr eme deta il ”
endor sed by health care pr ovid er and “ keeping in mind that expert reports .

. . are simply a preliminar y method to sho w a plaintiff has a viable cause of acti o n that i s n ot frivolous or
without e xpert support ” )

. Appe llants also focus o n the w eeks between Dr. Zac hari ah ’ s treat ment and
L iesenfelt ’ s death , including Liesenfelt ’ s hospital stay du ring this t ime period, to argue that

“ the report does no t draw a l i ne directly between an injury remote in t i me from the alleged n egligence. ” See Abshire , 563 S.W.3d at 22 5 ( requiring report to ad equately expl ain “ links in the causal c hain ” ) ; Greenville SNF, LLC v. Webster , No. 05

- 18

- 00038

- CV , 2018 Tex. App. LEXIS 10760 , at * 7 (Tex. A pp.

— Dall as Dec. 21, 2018, no pet .) (mem. op. ) ( “ An expert may show causat ion by explaining a chain of events th at begins with [th e
defendant ’ s] negligence and ends in injury to the plain tiff. ” )

. The alleged injury at issue , however , was not remote in time from Dr. Zac hariah ’ s care
. Dr. Sa lgado ’ s opinion was that the
infection remained and co ntinued to worsen afte r Dr. Zac hari ah ’ s allege d negligen t care

. And

“ [ n ] othing in section 74.351 suggests the preliminary report is required to r ule ou t every possible
cause of the injury, h arm, or dam ages claimed, especially given that s e ction 74.351(s) limits discovery befor e a medical expert ’ s rep ort is filed. ” Webster , 2018 Tex. App. LEXIS 10760 , at

* 20 (citation omitted)

.12 “ [T] he report need not explain how every causal lin k conne cts , ” “ explain the

mec han ism of inj ury , ” or provid e “ a n exhaustive explanatio n of the underl ying medical details. ”
Whee ler v. Luberger , No. 14

- 14

- 00992

- CV, 2016 Tex. App. LEXIS 263, at *17 (Tex. App.

— Houston [ 1 4 t h Dist.] 2 016, no pet. ) (mem. op.) ; se e Puppala v. P erry , 564 S.W.3d 190, 20 1 (Tex. App.

— Houston [ 1st Dist.] 2018, no pet.) ( rej ecting a rgu men t that “ the experts ’ opinions are conclusory because they fail to id entify when Perry ’ s abscess had grown and damaged his

s p inal cord to the point that his paralysis was ir reversible and they fail to compare the timing of
that event to when an MRI co uld ha ve been obtained had Puppala not breached the applicable
standard of care ” a nd observi ng that “ absence of an opinion statin g with specificity at what po int
in the continuum of disease progression an intervention would have proven timely does not caus e
the s e experts’ causation opinion to be conclusory at this early stage of evaluation ” )

. Based on its review of the entire repo r t , the trial c ourt within it s discretion c ould
h av e concluded that Dr. Sa lgado ade quatel y explained the causal c hain from Dr. Zach ariah’s alleged negligent care to Liesenfelt ’ s deat h by drawing a dire ct line from Dr. Zachariah ’s
breach es of the standard o f care , including no t order in g radiological testi ng on the lumbar spine

“ to ensure the in fectious process (the abscess) had not disse minated to the lumbar spine (which
was the location of the infec tion which ultimately led to her death) , ” to her death ( “[h ] a d the
lumbar infect ion been detected earlier, a s it probably would have if Dr. Zacharia h had complied with the applicable sta ndards of care, in all medi cal probability Ms. Liesenfelt would not have

u ltimately be come gravely septic (as the lumbar abscess c ould have been drain ed or re moved prior to sep si s deteriorating to the point of death) ” )

. See Abshire , 563 S.W.3d at 22 5

– 2 6 ( disagre eing that analytic gap existed in expert report and explaining that report adequately13 linked conclusion with underl ying fac t s , that “ failure to properly document Abshire ’ s medical
his tory was a substantial facto r in her de layed treatment and s ubsequ ent injury ” )

. W e conclude that th e trial court within its discretion co uld have concluded that Dr. Salgado ’ s causation opinion s were sufficient

. See i d. ; see also Potts , 392 S.W. 3d at 630

– 31 ( recognizing that “ exper t report does not require litigation

- r eady evidence ” and noting that
fun ctions of expert report are to “ inform the defendant of the specific conduct the plaintiff has
called int o question ” and “ p rovide a basis for the trial court to conclude that the claim s have
merit ” ) ; Christian Care Ctrs., Inc. v. Golenko , 328 S.W.3d 637, 6 48 (Tex. App.

— Dallas 2010, pet. denied) ( concluding tha t expert report sufficiently “ articula t e d the required causal
relati onship ” bet ween all eged failure to me et applicable standards of care a nd plaintiff ’ s death ); UHS of Timberlawn, I nc. v. S.B

. , 281 S.W.3d 207, 213

– 15 (Tex. App.

— Dallas 2009, pet.
deni ed) (c oncluding that expert report suffic ient l y linked health care provide r ’ s negligence with allege d harm or injuries to provide suffi cient bas is for trial court to conclud e that claim had merit
and that tr ial court did not abuse discretion in d enying motion to dismiss ) ; cf. Colum bia N. Hills Hosp., Subsi diary, L.P. v. Tucker , No. 05

- 14

- 00056

- CV, 2014 Tex. App. LEXIS 13685, at *6 (T ex. A pp.

— Dallas Dec. 22, 2014, no pet.) (me m . op.) ( review ing causa tion opinion “ in the context of the entire report when assessing its sufficien c y ” and observing that exp e rt was not required to rule out all p ossible ca uses of claimant ’ s injuries b ut conc l uding that expert report

was in ade quate on element of c ausation )

. 5

5 A s suppor t for the ir position that Dr. Salga do ’ s expert report was insu f ficient as t o causation, a p p ellants rely on Karkoutly v. Guerrero , No. 1 3

- 17

- 00097

- CV , 2017 Tex. App. LEXIS 11604 (Tex. App.

— Cor pus Chr isti

- Edinburgh Dec. 14, 20 17, no pet.) (mem. op.) , but in that case, the expert report i tself “ discussed three potential sources of [th e patient ’ s] in fect ion ” and contained significant o missions concern ing the exploratory surgery that the defendant physician was al le gedly negli g ent by not prompt ly recomme nding , id. at * 9

. In contrast,14 Standa rd of Care
In t heir second sub

- issue , appellant s ar gue that the trial court abused its disc r etion by impliedly finding that Dr. Sal gado ’ s exp ert report identif ie d and adequately summa r ize d the applica ble standar d of care f or Dr. Za char ia h a nd the manner in which he breached that standard
of ca re. Appellants contend that the repo rt fail ed to in f orm Dr. Zachariah “ o f the specific
conduct called into que stion ” and “ pr ovide [d] internally i nconsistent opinions about the

appr opr iate actions of a physician in the setting o f a p rior staph infection and findings of
localized ba ck te nderness. ”

“ To ad e quately identify the s tand ard of care, an expert r ep ort must set forth

‘ specific information ab out what the defendant should have don e differently

. ’ ” Abshire , 563 S.W.3d at 22 6 (quoting Palacios , 46 S.W.3d at 880 )

. “ While the Act require s only a ‘ fair

s u mmary ’ of the standard of c are and how it was brea che d, ‘ even a fair summary must set out
what care was expected, but n ot given. ’ ” I d. (quotation omitted). At t h e preliminary sta ge of the
TML A ’ s exp ert report requir e ment , however, wheth er the articulate d “ standards appear
reasonable i s not rel evant to t he analysis. ” Id. (quoting Miller , 536 S.W.3 d at 516

– 17).
In additi o n to th e por t ion of the amended report qu oted above , Dr. Sal g a do opi ne d

a

bout the applicable standard s of care for a fam ily physicia n like D r. Zach ariah and his b re ach es
of the stand a rd s of care , inclu ding opining :

Dr. Salgado ’ s report d id not discuss al ternative sources of the infection , and his opinion on
caus ation is consist ent with the epidural abs cess that was found through sub sequent radiological testing

. Cf. Jelinek v. Casas , 3 28 S.W.3d 526, 536

– 37 (Tex. 2010) (in context of jury trial, concludin g that causation evidence was insuffi cient because ex pert ’ s conclusion that undetected infection was present was undermined by conce ssion t hat sy mpt oms were consistent with infections no t tre atable by certain medicines and ex plaining that it was equally pla usible that patient had infection or did not).15 The standard of c are applicable to a family physician like Dr. Zachariah, on presentme nt of Ms. L iesenfelt’s s y mpto ms including tenderness to the lower back, should have bee n to order a lumbar spine x

- ray to identify the pot ential cause(s) of the spinal tenderness , for t he purpose of identifying bone infecti on that can develop into an absce ss down the line. An x

- r ay c oul d rule out bone findings consistent with bone infection , which is an initial indic ation of an abscess. If the
x - ray is abnormal as listed in the previou s se ntence, or if the symptoms of lowe r back pain continued in spite of a normal x

- ray and with know led ge of the recent superficial skin infection (the absces s Dr. Zachariah removed on 6/20/ 18 was an infection ), an MRI of the lumbar spine should have been or dered. The MRI can more definitivel y demonstrate the presence of an a bscess in t he lumbar spi ne (t he location of Ms. Liesenfelt’s pain), which would be an o ngoing infection. Further, give n the abscess remov ed from Ms. Liesenfelt’s shoulder on 6/20/18 , t he standard of care applicable to Dr. Zachariah required him to schedule [ a ] follow

- u p appointme nt no l ater than two weeks later to ensure there was no dissem i nation of the infect ion.

* * * Therefore, Dr. Zach ari ah breached the stand ards of care identified above by not ordering any ra diologica l testing concurren t ly with his 6/20/18 abscess removal (n either an initial x

- ray nor a s ubsequent MRI as the sta ndard o f care outlined above dem anded), b y not insisting o n a prompt follow

- up following the 6/20/18 absc ess removal (ther e was no follow

- up ap pointment s chedul ed, let alone one within two weeks as the sta nda rd of care demanded), and by not ordering any radiologi c al testing following the 7/23/1 8 visit de spite his knowledge of Ms. Liesenfelt ’ s infectious proce ss and desc ribed te nder ness to palp ati on of the lower back.

Ap pellant s characterize Dr. Salgad o ’ s rep ort as con taining opinions on the required standard s of care that are contradictory an d internally inconsi stent , thereby prohibiting
the trial court from conclud ing that Durtschi ’ s negligence c laims have merit. R eferencing
Dr. Salgado ’ s comments about oth er health care providers in the report , appellants q ues t ion why
the su bsequent provider s ’ standard of care would not have required the r adiology te sting and
follow

- up that Dr. Salgado opine d w as the applic able stand ard of care for Dr. Za cha riah

. For

examp le , a ppell ants contend that Dr. Sal gado ’ s c omments in t h e section summari zing medical

e ve nts about a “ ve ry uneventful ” hos pital sta y at the end of July e spous e d his opi nion that the16 subsequen t health care providers “ p r esumably met the sta ndard of care ” but there was “ n o
indicat ion that the patient was instruct e d to follow up ” f rom the hospit al sta y
. Based o n the

presu mption that Dr. Salgado believed that the subsequent health care providers m et the standards of care, a p pellants ar gue that Dr. Salgado ’ s sta te ments in his report about the ir care

w ere incons isten t with his opinio n that Dr. Zach a riah was negligent

. Dr. Sal gado , however, d id not address the a p plic able standard s of care for the

su bsequent health care providers , and our review of the adequacy of his opi nions as to the applicable standard of care f or Dr. Zacharia h is limited to the f our corners o f the re port

. See Baty , 543 S.W.3d at 693 ; Wright , 79 S.W.3 d at 52

. Dr. Salgado opin ed that given Li e senfelt ’ s
pre sentment and dia gnosis , Dr. Zacha riah should have o rd ered a l umbar sp i ne x - ra y or MRI and
scheduled a follow

- up visit within t w o weeks t o en su re there was not dissemination of the
in fection. He explained that the reaso n for orde ring a lumbar spine x

- ra y wa s “ to reveal the

pres ence of any bo ny or soft t issue abnormalities ” and that the x - ray could have identif ie d the

“ potential cause (s) of the s pinal tenderness, for the purpose of i dentifying bone infection that can develop into a n abscess down the line

. ” A nd he provided unde rl ying facts , including that “ [t]he
abscess is an infecti o us process ” and that Liesenfelt “ was seen by the same physician (Dr

. Zachariah) whom had susp ected and treated se vere i nfectious processes to her back and
shoulder and hence had the luxury of havi ng n ot just access to records (as it was the sa me clinic ),
but first

- hand knowledge of Ms. Liese nfelt ’ s he alth background an d t herap ies. ”17 At this prelimin ary stage , t he tr ial court within its discretion cou ld have found that
the r eport was sufficient as to th e applicable standard s of care for Dr. Zachariah and hi s alle g ed
breach e s of th ose standard s
. 6 See Abshire , 563 S.W.3d at 22 6

.
Qualification
In their third and fo urth sub

- issues , appellants argue tha t t he trial court abused its discretion by imp liedl y finding that Dr. Salgado was qualified to rende r an o p inion on the

sta ndard o f care for Dr. Zachariah, “ an out patie nt

- clinic

- based family pract ice p hysician , ” and on
the causa l connection b etween Dr. Zachar iah ’ s treatment and Liesenfelt ’ s injur ies a nd de ath

“ from an epidural abscess caused by [MRSA]

. ”
To be qu alified as an expert in a suit against a p hys ician on th e a pplicable
standard of care , the exper t physician must b e practicing medicine at the time t he testimony is given, have knowl edge of the a ccep ted standards of medical car e, and be qualified ba s e d on training or ex pe rience

. See Tex. Civ. Prac. & Re m. Code § § 74. 351(r) (5)( A), . 401 (a) ; Collin i

v. Pustejov sky , 280 S.W.3d 456, 462 (Tex. App.

— Fort Wor th 20 09 , no pet.) ( “ An exper t report
concernin g standards of care for physician s ‘ authored by a perso n who is not qual ified to testify

. . . cannot constitute an a dequ ate report. ’ ” (qu oting In re Windisch , 138 S. W.3d 507 , 511 (Tex. App.

— Amarillo 2004, no p et.) )

. In det ermining wh ether a physician is qualified based on his

6 We fi nd appellants ’ cited authori ties addressing inte rnal inconsistencies with in expert rep orts to be fac tually distin guisha bl e
. See , e.g

. , Hebert v. H opki ns , 3 9 5 S.W. 3 d 884, 894 (Tex. App.

— Austin 2013, no p et.) (considering whe ther trial co urt abused its discretion in gra nting motion to d ism i ss and addressing expert ’ s “ recogni tion of an app ar e nt exce ption , qua lification, or limitation to h is broader criticisms of anterior fixation ” ) ; Fung v. F is cher , 365 S

. W

. 3d 507, 5 31 (Tex. App.

— Austin 20 1 2 , no pet.) (noting that incons istency concerned physicia n ’ s actual knowledge of condition at issue and t hat “ re port affir matively ne g ates Fung ’ s having seen the information that is key to his li ability ” ) , overrule d in p ar t on other grounds by Certified EM S, Inc. v. Potts , 392 S.W.3d 625, 630 (Tex. 2013)

.18 tra ining and experience , the tri a l court consider s if he is b oar d certified or has other subst an tial

tra ining or experience in an area of medical pract i ce r elevant to the claim and “ is ac tively practicing medicine in rendering medi cal care services rele vant to the claim. ” Tex. Civ. Pr a c . & Rem. Code § 74.401(c); Armenta v. Jones , No. 01

- 17

- 004 39

- C V, 2018 Tex. App. LEXIS 1586,
at *7

– 8 (Tex. App.

— Houston [ 1st Dist.] Mar. 1 , 2018 , no pet.) ( mem. op.)

. The focus in
de termining if an e xpert is qualified “ is on the fit between the subject m a tter at issue and the
expert ’ s familiarity ther ewith, and not o n a c omparison of the expert ’ s title or speci al ty w ith th at
of the defendant

. ” McKowen v. Ra gst on , 2 63 S.W.3d 157, 1 64 (Tex. App.

— Houston [ 1st Dist.]
20 07, no pet.) ( citation and int er nal quotations o m itted)

. In h is am ended rep ort, Dr. Sal g a do listed h is certific ations and areas of practice,
stated that his o pinions were based on his “ education , publications, research, present ations, and
medical experi ence ” as outlined in his CV , and further address e d his qualificati ons as fo llows:

Based on my educa tion , training, experience, and current practice, as more full y outlined in my CV , I have knowledg e of and am qualified to opine on the standards of c a re applicable to family physi cians per forming procedur e s like A veen Zachariah in this case

. Based on my educ a tion, training, experience, and current practice, as more fully outlined in my CV , I have kno wledge of and am qualified to opine on the causal co nnection between breaches of standards of care by f amil y physicians performing procedures l ike A veen Zachariah in this case an d the in j uries and ultimate d eath like tha t suffered by Doris Liesenfelt in th is case

. My conclusions have been drawn to a reason able degree of medical certainty and probability fr om t h e standpoin t of a qualified physic i an wh o treats patie nts with similar pathologies.

Dr. S algado ’ s CV reflects th at h e is board certified in internal and cr itical care medicine and that
he has knowledg e of and experience with s epsis. Appellants asser t t ha t Dr. Salgado , “ a lung transplant physician working in a hospital se tting, ” is unqualifie d to opin e about the st a nda rd of car e of “ a family physici a n in a19 clinical setting , ” “ for the evaluation and treatment of back pain and a superfic i al sho ulder
absce s s caused by m ethicillin

- sensitive staphylococcus aureu s
. ” Appellants rely on the following omiss ions in the exper t report and CV : (i) “ [ t ] he report and CV do not state that
Dr. Salgado has eve r evalu ated or treated ba ck p ain or a shoulder abs cess in any s etting , let alone
an office

- based walk

- in cl inic ” ; (ii ) the phra se “ f a mily practice ” does not appear o n h is C V ; a nd (iii) he is n ot b o ard certi fied a n d has not completed training specific to family me dicine

. They also argue that Dr. Salgado ’ s experience w ith sepsis was 10 years prior t o Dr. Zachariah ’ s care
and that the e xp ert report and CV do not spe ci fically addre ss Dr. Salgado ’ s knowledge,

tra ining , or experience with “ skin abscesses , bony spinal i nfec tions, epidural abscesses, or

st aph infections

. ”
T o be qualified to opin e on the standard of care, howev er , an expert do es not have
to be a specialist in the same practice area as the defendant phys i cian

. See McKowen , 2 63 S.W.3d at 16 5

– 6 6

. D r
. Salg ado i s b oard certified in c ritical care and in ternal me d ic ine,

a substantially similar bra nch of medicine to f ami ly practice m edicine for the treatment of
adu lts , 7 a nd t he subje ct matter s at issue primaril y involve an “ infectious process ” and s epsis , both of which Dr. Salgado has experience and familiarity

. S e e id. at 164 ; see also Armenta , 2018 Tex. App. LEXIS 1 586, at * 11

– 12 ( concluding that an e sthesiologist was qualif ied to t estify against plastic surge on about standard of care “ regarding matters common to and equally recognized and developed in all fields o f practice ” ); Khan v. Ramsey , No. 01

- 12

- 00169

- CV,

7 In his re s ponse to appellants ’ motion to dismiss, D urtschi provided the trial court with general i nformation fr om the American College of P hysicians that showed that fa mily practi ce and i nternal medicin e are substantially similar. I nternal medicine p ractitioners treat only adults , and family medicine prac ti ti one rs treat adults and children , but int ern al m edicine and family practice phys ician s func tion as primary care ph ysicians

. See https://www.acponl ine.org/about

acp/about

- internal

- med icine/career

- paths/medical

- student

- career - path/internal

- medicine

- vs family

- medicine (last visited May 10, 2022 )

.20 2013 Tex. App. LEXIS 2981 , at * 14

– 1 6 (Tex. App.

— Houston [1st Di st.] Mar. 21, 2013, no pet.) (mem. o p.) ( concluding that exp ert wh o wa s fa m ily prac tice physician was qualified to testify against i nternal me d icine specia list ; that “ if t h e s ubject matter is c ommo n to and equally recognized and developed in all fields of pra ctice, any physician familiar wit h the subject may testify as to the standard of car e ” ; and that pre vention of infection is common and equa l ly recognized and deve loped in all fields of pract ice ( citing Keo v. V u , 76 S.W.3d 725, 732 (Tex

. App

. — Houston [ 1 st Dist.] 2002, pet denied) ) ; Garza v. Keil lor , 623 S.W.2d 669, 671 (Tex. App.

— Houston [1 s t Dist.] 1981, writ ref ’ d n.r.e.) ( concluding that t rial court did not abuse
di scretion in per mitting inter n al medicine pra cti ti oner to te s tify as expert against defe ndant
orth opedic surgeons about st an dard of care in “ infection process ” ) ; cf. Wigley v. Shann on Med.
C t r. , No. 03

- 17

- 00086

- CV , 2017 Tex. App. LEXIS 11177, at *12

– 13 (Tex. A pp.

— Austin
Dec. 1, 2017 , no pet.) (mem. op.) (concludi ng that trial cour t did not er r in granting s ummary judgment where expert physic ian , who was intern al med icine pr actitioner and generally fa miliar with pressure ulcers , did not show th at he was qualified to testif y c oncerning p articular subject at issue, p ressure ulcers tha t dev elop ed on trauma and ICU patient at h ospita l)

. Appellants also asser t that Dr. Salgado is not q ualified “ to render an expert opinion about th e causal connectio n between Dr. Zach ariah’s treatment and L iesenf elt’s inj uries
and death from an epidural abscess cause d by methic illin

- resistant staphyloc occus aureus
. ” To be qualified to tes tify as an expert on causation, the p hysician must be “ otherwi s e qualified to
render opinions on that causal relationship under the Texas Rules of E vidence

. ” Tex. Civ. Prac

. & Rem. Code § 74. 351(r) (5)( C ) ; see id. § 74 .403 (a) ( addr ess ing qualification of e xpe rt wit ness
on causation in h ealth care liability claim against physician or health c are provider )

. The Rules
of Evide nce require an expert to ha ve “ knowledge, skill, exper ience, trainin g, or education ”21 regarding th e specific fact at is sue
. Tex. R. Evid. 702 ; see Cornejo v. Hilgers , 4 46 S.W.3d 1 13,
12 1 (Tex. App.

— Houston [1st Dist.] 201 4 , pet. denied) ( explaining that “ p laintiff must show that her expert has ‘ knowledge, skill, exp erience, t raining, or educat ion ’ reg arding the specific issue before the court that would qualify the exp er t t o give an opinion on that particular subject ” ( quo t ing Broders v. Heise , 924 S.W.2d 1 48, 153

– 54 (Tex. 1996) ))

. Appellants argue t hat Dr. Salga do ’ s c ausati on opinions “ necess arily r equire knowledge pertaining to infectiou s disease, orthopedics , epidu ral abscesses,
rad iology/ne uroradiology, neurosurg ery, a nd pathology ” a nd that “ [ h ] i s CV a nd report do not demonstrate that he has knowledge, skill, ex perience, training, or educat ion in any of these specific areas

. ” An expert physician , however , is not r equired to have pr acticed i n every medical discipl ine i n vol ved in the care of the pa tient, so long as he “ has practical knowledge of what is usually an d customar ily done by other practiti oners under circumstances similar to those confronting the malpractic e defendan t. ” K eo , 76 S.W.3d at 732

. Further, “ [ w ] hen a trial court finds for purposes o f chapter 74 that a physician i s qualified to give his expert opinion a bout the
standard of care for a certain procedure , it is reas onable fo r the trial court to co nc lude that the physician is quali fied to opine on the ca u sal relationship between the failu re to meet that
standard and the resul ting harm

. ” Legend Oak s
- So uth Sa n Antonio, LLC v. Molina , No. 04

- 14

- 00289

- CV , 2015 Tex. App. LEXIS 152 4, *14 (Tex. App.

— San A nt onio Feb. 18, 201 5 , no pet.) (me m. op.) (c iting Whisena n t v. Arnett , 339 S.W.3d 920, 927 ( Tex. App.

— Dallas 2011, no pet.) )

. Based on our review of Dr . Salgado ’ s CV and report, w e cannot conclude that the
trial court abused its discretion in overruling ap pellants ’ objections to Dr. Salgado ’ s qualifications to render an opinion on standard of c are and c ausation

. S ee Whit mire v. Feathers ,22 No. 01

- 19

- 00094

- CV , 2020 Te x. App. LEXIS 6804, at * 30 (Tex. App.

— Houston [ 1 st Dist.] Aug . 25, 2020, no pet.) (m em. op.) ( “ Whether an expert witness is qualified to offer an ex p ert opinion lies within the sound discretion of the trial court. ” (citing Cornejo , 446 S.W.3d a t 121 ) ) ;
Molina , 2015 Tex. App. LEXI S 1524, at *14 ( concluding that trial court could reasonably have

co nc luded that physician wa s qualified to state his opini o n because his repo rt demonstrate d

t raining, knowledge, and experience with issues involved in un derlying c laim )

.

Conclusion as t o T rial C ourt ’ s I mplied F in dings
We hold that the trial court act ed w ithin its discretion when it impliedly found that
D r
. S algado was qualified and that hi s report rep resents a good faith effort to provide a fair

summ ar y of hi s opini ons regarding the appl icable standards of care, Dr. Zachariah ’ s fail ure to
meet those s tandards, and the causal rel ationship between the failu r e and the harm claimed. See
Tex. C iv. Prac. & Rem. Code § 74.351( l ), (r)( 6). The report sufficien tl y links Dr. Sal gado ’ s
conclusions to the facts, gives appellants fair notice of the complaints against them , and is sufficient to have permitted the t rial court to conclude that there is mer it to one or more of the
claims. See Abshire , 563 S.W.3d at 224 ; Potts , 392 S.W.3d at 630

. We over rule appellants ’
first is sue.
Attorney ’ s Fees and Costs
Because we hav e concluded that the tria l court did not abuse its discretion in overruling appel lants ’ objection to Dr. Salgado ’ s amended expert report and in d eny ing th eir

mo tion to dismi ss , we also conclude that the trial co urt did not abuse its discreti on in denying their reque st for an award of attorney ’ s f e es and costs. See Tex. Civ. Prac. & Re m. Code § 74.351 (b) (1 ) ( requiring tri al co ur t to awar d attorne y ’ s f ees and cos ts to def endant physician or23 heal th care provider when expert report is not s erv ed within s ta tutory deadline). We overrule
their se c ond issue.

CONCLUSION Having overruled app ellants ’ issues, we affirm the trial court ’ s order overruling
their objections t o Dr. Salgado ’ s expert r e p ort and denying their motion to dismiss

.

___ __ _____________________________________ Meliss a Goodwin , Justice
Before Ju stic es Goodwin, Triana, an d Smith
Affirmed
Filed: May 13, 2022