Source: https://www.benglasslaw.com/library/virginia-tummy-tuck-malpractice-case-to-proceed.cfm
Timestamp: 2019-04-21 13:10:53+00:00

Document:
Appeal from a judgment of the Circuit Court of Fairfax County. Hon. David T. Stitt, judge presiding.
R. Harrison Pledger, Jr.; John E. Peterson, Jr. (Pledger & Associates, on brief), for appellant.
(Joseph Peter Drennan; Sam W. Burgan; Burgan & Associates, on brief), for appellee.
In this medical malpractice action, we address two issues: (1) the fact that the plaintiff's only medical expert witness did not state his opinion to a reasonable degree of medical probability; and (2) the [Page 133] sufficiency of the evidence. Because the defendant did not make a contemporaneous objection when the medical expert's testimony was introduced, the defendant's motion to strike the expert's testimony made at the close of the plaintiff's evidence was not timely, and the objection was therefore waived. Thus, the jury properly considered the expert's opinion. With regard to the sufficiency of the evidence, we conclude that the plaintiff presented sufficient evidence establishing that the defendant breached the standard of care and that the breach was a proximate cause of the plaintiff's injury. Thus, the circuit court's judgment in favor of the plaintiff was neither plainly wrong nor without evidence to support it. We will therefore affirm that judgment.
The appellee, Wafa Rahman, underwent an abdominoplasty, a surgical procedure commonly known as a “tummy tuck.”1 The appellant, Dr. George J. Bitar, performed the surgery in March 2003. During an office visit on the day prior to the scheduled procedure, Dr. Bitar made pre-operative markings on Rahman's abdomen in preparation for the surgery. According to Dr. Bitar, he used those markings as points of reference or guidelines during the surgery so that he would know if he was cutting approximately the same amount of skin from the right and left sides of Rahman's abdomen. Dr. Bitar indicated that the markings were necessary because tissue moves around when a patient lies on the operating table.
A: What I am saying is that the apparent predetermination of tissue was a deviation. It should not have been predetermined, at least according to this marking.
Number two, I believe that too much tissue was removed leading to the suturing of the flap under such tension that the blood supply was compromised and the tissue eventually died. That's what I'm saying.
Q: And if that was not a predetermination of what tissue would be removed but simply a guideline for him and what he did was to undermine it, as you indicated, and he brought the tissue down and trimmed off what was excess over the lower side of the cut, that's what you do, isn't it?
Q: And if he did that, then he didn't breach the standard of care, even if it did break down thereafter?
A: I believe, again, with a — with a result of this magnitude something went horribly wrong. And it's a matter of judgment as to . . . how much tissue you can safely remove. That comes with experience.
At the close of Rahman's evidence, Dr. Bitar moved to strike Dr. Jacobs' testimony and to enter judgment in favor of Dr. Bitar. He argued that Dr. Jacobs failed to express an opinion to a reasonable degree of medical probability that Dr. Bitar had breached the standard [Page 136] of care and that the breach was the proximate cause of Rahman's injuries. Dr. Bitar emphasized the point that Dr. Jacobs never expressed an opinion to a reasonable degree of medical probability. The circuit court took Dr. Bitar's motion under advisement.
[A]t no time was Dr. Jacobs ever asked to express an opinion with reasonable medical certainty with respect to the standard of care.
There is no doubt that he stated that in his opinion Dr. Bitar erred because he planned to remove more tissue and, therefore, preplanned it and did, in fact, upon the execution remove more tissue than he should have removed thereby creating a situation where excess tension was placed upon the abdominal flap resulting in inadequate blood supply to what I guess has been termed as area two or the area below the navel and that as a result . . . that area suffered from ischemia and the death of that tissue leaving a cosmetically displeasing appearance to her lower abdomen.
If he had coupled that with the statement that — with reasonable medical certainty or reasonable medical probability . . . he would have perhaps met the standard of care; but he didn't do that.
The circuit court denied the motion, explaining that although “the general rule is that medical expert opinion must be rendered to a reasonable degree of medical probability[,] . . . the appropriate time for [the motion] was at the time the witness offered the opinion[,] . . . not after the opinion is in the record.” The circuit court also denied Dr. Bitar's motion to reconsider the denial of his motions to strike Dr. Jacobs' testimony and to strike Rahman's evidence.
The jury then returned a verdict in favor of Rahman and awarded damages in the amount of $20,000. Following the verdict, Dr. Bitar filed a written motion to set aside the jury verdict and to enter judgment as a matter of law in his favor. Dr. Bitar argued that Rahman failed to present expert testimony in three areas: (1) what the standard of care required Dr. Bitar to do with regard to Rahman's surgery; (2) that Dr. Bitar breached the standard of care; and (3) that [Page 137] any such breach was a proximate cause of Rahman's damages. Dr. Bitar also asserted that, to the extent Dr. Jacobs offered an opinion, he did not do so to a reasonable degree of medical probability. The circuit court acknowledged that Dr. Jacobs had not been asked whether his opinion was to a reasonable degree of medical probability. Nevertheless, the circuit court again concluded that an objection on that basis was untimely. The court also stated Dr. Jacobs had testified that Dr. Bitar had breached the standard of care and that his testimony went beyond “mere possibilities.” Thus, the circuit court denied the motion and entered judgment for Rahman in accordance with the jury verdict. Dr. Bitar now appeals to this Court.
Dr. Bitar raises two issues on appeal. He asserts that the circuit court erred by permitting the jury to consider Rahman's medical malpractice claim and by thereafter failing to set aside the jury verdict because: (1) Rahman's expert witness failed to state an opinion to a reasonable degree of medical probability; and (2) Rahman's expert witness failed to present sufficient evidence to establish that Dr. Bitar had breached the standard of care and that the breach was a proximate cause of Rahman's injury. We will address the issues in that order.
 In doing so, we are guided by well-established principles of appellate review. Armed with a jury verdict approved by the trial court, Rahman stands in “the most favored position known to the law.” Ravenwood Towers, Inc. v. Woodyard, 244 Va. 51, 57, 419 S.E.2d 627, 630 (1992). She is entitled to have the evidence, and all inferences that may reasonably be drawn from it, viewed in the light most favorable to her. Norfolk S. Ry. Co. v. Rogers, 270 Va. 468, 478, 621 S.E.2d 59, 65 (2005); Evaluation Research Corp. v. Alequin, 247 Va. 143, 147, 439 S.E.2d 387, 390 (1994). The judgment of the circuit court will not be set aside unless it is “plainly wrong or without evidence to support it.” Code § 8.01-680; see also Norfolk Southern, 270 Va. at 478, 621 S.E.2d at 65.
[2-4] In a medical malpractice action, “a plaintiff must establish not only that a defendant violated the applicable standard of care, and therefore was negligent, the plaintiff must also sustain the burden of showing that the negligent acts constituted a proximate cause of the injury or death.” Bryan v. Burt, 254 Va. 28, 34, 486 S.E.2d 536, 539-40 (1997); see also King v. Sowers, 252 Va. 71, 76, 471 S.E.2d 481, 484 (1996) (“[t]he relevant issue . . . is whether the treatment [Page 138] rendered violated the applicable standard of care and whether any such breach of the standard of care was a proximate cause of the plaintiff's injury”). “‘[E]xpert testimony is ordinarily necessary to establish the appropriate standard of care, to establish a deviation from the standard, and to establish that such a deviation was the proximate cause of the claimed damages.’” Perdieu v. Blackstone Family Practice Ctr., Inc., 264 Va. 408, 420, 568 S.E.2d 703, 710 (2002) (quoting Raines v. Lutz, 231 Va. 110, 113, 341 S.E.2d 194, 196 (1986)); see also Rogers v. Marrow, 243 Va. 162, 167, 413 S.E.2d 344, 346 (1992). To be admissible, such medical expert testimony must be rendered to a “reasonable degree of medical probability.” Pettus v. Gottfried, 269 Va. 69, 78, 606 S.E.2d 819, 825 (2005); see also Spruill v. Commonwealth, 221 Va. 475, 479, 271 S.E.2d 419, 421 (1980) (“[a] medical opinion based on a ‘possibility’ is irrelevant, purely speculative and, hence inadmissible”).
 This last principle is central to our consideration of the first issue, whether the circuit court erred by allowing the jury to consider the medical malpractice claim since Dr. Jacobs never expressed his opinion to a reasonable degree of medical probability. Dr. Bitar argues not only that Dr. Jacobs' testimony was based on possibilities instead of probabilities but also that his opinion lacked an adequate factual foundation and did not take into account all the variables that could bear upon the inferences to be drawn from the facts.6 It is correct that Dr. Jacobs never stated his opinion was based on a reasonable degree of medical probability. Rahman, however, contends that Dr. Bitar's argument premised on this omission in Dr. Jacobs' testimony is actually an objection that should have been raised contemporaneously with the introduction of Dr. Jacobs' testimony rather than at the close of Rahman's evidence, after her other witnesses had testified.7 We agree with Rahman's position.
In Mueller v. Commonwealth, the defendant argued that portions of a forensic pathologist's testimony should not have been admitted because the pathologist expressed opinions that were not stated to a “reasonable degree of medical certainty.” 244 Va. 386, 410, 422 S.E.2d 380, 395 (1992), overruled in part on other grounds by Morrisette [Page 139] v. Warden of Sussex I State Prison, 270 Va. 188, 202, 613 S.E.2d 551, 562 (2005). Because the defendant failed to make a contemporaneous objection during the pathologist's testimony to the admission of objectionable opinions, we refused to consider the argument on appeal. Mueller, 244 Va. at 410, 422 S.E.2d at 395.
Similarly, in Spruill, a psychiatrist testified that there was a “possibility” that the defendant was insane on the day the crimes at issue were committed. 221 Va. at 479, 271 S.E.2d at 421. We upheld the trial court's decision refusing to admit the testimony. Id. We stated, “[a] medical opinion based on a ‘possibility’ is irrelevant, purely speculative and, hence, inadmissible.” Id. (emphasis added); accord State Farm Mut. Auto. Ins. Co. v. Kendrick, 254 Va. 206, 208-09, 491 S.E.2d 286, 287 (1997); Fairfax Hosp. Sys. v. Curtis, 249 Va. 531, 535, 457 S.E.2d 66, 69 (1995). We reached the same conclusion in Pettus, when a doctor's answer to a question “offered an expert opinion that was speculative in nature and inadmissible because it was not stated to a reasonable degree of medical probability.” 269 Va. at 78, 606 S.E.2d at 825 (emphasis added); see also Vasquez v. Mabini, 269 Va. 155, 160, 606 S.E.2d 809, 811 (2005) (expert testimony founded upon assumptions having no factual basis is inadmissible, and failure of the trial court to strike such testimony upon a timely motion is error); Countryside Corp. v. Taylor, 263 Va. 549, 553, 561 S.E.2d 680, 682 (2002) (“expert testimony is inadmissible if the expert fails to consider all the variables that bear upon the inferences to be deduced from the facts observed”); John v. Im, 263 Va. 315, 319-20, 559 S.E.2d 694, 696 (2002) (expert testimony is inadmissible if it is based on an inadequate foundation, is speculative, or is founded on assumptions lacking a sufficient factual basis).
 The general standards for timely motions to strike the evidence for insufficiency are inapplicable to objections regarding the admissibility of evidence. As we have previously held: “[a] litigant may not, in a motion to strike [the evidence], raise for the first time a question of admissibility of evidence. Such motions deal with the sufficiency rather than the admissibility of evidence.” Woodson v. Commonwealth, 211 Va. 285, 288, 176 S.E.2d 818, 821 (1970); see also Poole v. Commonwealth, 211 Va. 258, 260, 176 S.E.2d 821, 823 (1970).
 Since Dr. Bitar did not move to strike Dr. Jacobs' testimony or raise any objection to its admissibility until after Dr. Jacobs was excused and had returned to New York, and the testimony of several other witnesses was presented, the objection was too late. Although Dr. Bitar couches the first issue as a challenge to the sufficiency of the evidence, it presents only a question regarding the admissibility of Dr. Jacobs' testimony, which was waived because the objection was not timely raised during the trial.9 See TransiLift Equip., Ltd. v. [Page 141] Cunningham, 234 Va. 84, 91-92, 360 S.E.2d 183, 187-88 (1987) (if a party does not timely object to the admission of evidence, the objection is waived).
 Thus, with regard to the first issue, we conclude that the circuit court did not err by allowing the jury to consider Rahman's medical malpractice claim merely because Dr. Jacobs did not express his opinion to a reasonable degree of medical probability. Dr. Jacobs' testimony, having been admitted without objection, was properly considered by the jury.
[I]f a litigant sits by and permits evidence to go to the jury which the court, if it had been objected to, would have excluded, the jury have the right and it is their duty to consider it along with all the evidence and give it such weight as they think it is entitled to.
Id. (quoting Newberry v. Watts, 116 Va. 730, 736, 82 S.E. 703, 705 (1914)).
We now consider the second issue, whether the evidence was sufficient to establish that Dr. Bitar breached the standard of care and that such breach was a proximate cause of Rahman's injury. Our resolution of that issue turns on the testimony of Dr. Jacobs, who was Rahman's only medical expert witness.
 In addressing the issue, we are mindful that Dr. Bitar challenged the sufficiency of the evidence at the close of Rahman's evidence, at the close of all the evidence, and in a motion to set aside the jury verdict. The standard of appellate review, however, is the same in each instance.
[W]here the trial court has declined to strike the plaintiff's evidence or to set aside a jury verdict, the standard of appellate review in Virginia requires this Court to consider whether the evidence presented, taken in the light most favorable to the plaintiff, was sufficient to support the jury verdict in favor of the plaintiff.

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