Case Name: Paige Lohr v. Douglas Larsen, M.D.
Court: Supreme Court of Virginia
Jurisdiction: Virginia
Decision Date: 1993-06-11
Citations: 246 Va. 81
Docket Number: Record No. 921180
Parties: Paige Lohr v. Douglas Larsen, M.D.
Judges: 
Reporter: Virginia Reports
Volume: 246
Pages: 81–92

Head Matter:
Paige Lohr v. Douglas Larsen, M.D.
Record No. 921180
June 11, 1993
Present: All the Justices
Thomas E. Albro (Christine Thomson; Tremblay & Smith, on briefs), for appellant.
Marshall H. Ross (Ronald D. Hodges; Charles F. Hilton; Wharton, Aldhizer & Weaver, on brief), for appellee.

Opinion:
JUSTICE WHITING
delivered the opinion of the Court.
In this medical malpractice case, we decide whether a state-employed public health physician is entitled to the protection of the doctrine of sovereign immunity from liability for his alleged acts of ordinary negligence.
Paige Lohr filed this action against Dr. George Douglas Larsen, a salaried state employee, alleging medical malpractice on his part in failing to order mammograms and needle biopsies after Dr. Larsen detected a lump in Lohr's right breast. After hearing evidence and argument of counsel, the trial court sustained Dr. Larsen's plea of sovereign immunity and dismissed the motion for judgment. Lohr appeals.
No transcript of the evidence or statement of facts has been filed. Therefore, we state the pertinent facts from the allegations of negligence in Lohr's motion for judgment (which the trial court accepted as true for the purposes of its ruling) and from the trial court's findings of fact as stated in its opinion letter.
In July 1988, Lohr went to the Waynesboro Public Health Clinic seeking birth control pills that are issued under its family planning program. This clinic, funded by the Commonwealth and by local governments to supply limited public health services to citizens who cannot afford to pay for private health services, is controlled and staffed by the State Department of Health.
After establishing her eligibility for the program, Lohr returned to the clinic on July 14, 1988. There, in conformity with state regulations, a public health nurse updated Lohr's medical history, provided Lohr with patient education, and took a blood sample. Dr. Larsen then examined Lohr.
The Commonwealth required that Lohr have a physical examination before Dr. Larsen could prescribe birth control pills. Included within the state-defined scope of the examination was a breast examination. However, because the Commonwealth does not provide the funds, equipment, or authority for further examination or treatment, should the need for further medical services become apparent in such an examination, the person examined is referred to other health care providers for treatment.
Dr. Larsen, a board-certified obstetrician and gynecologist, was assigned by the Commonwealth to provide certain medical services to the clinic. The trial court described the Commonwealth's control of Dr. Larsen's function at the clinic in the following language:
[T]he State . . . controls, absolutely, when and where Dr. Larsen works, the number and identity of the patients he sees, the equipment he uses, the procedures he can perform and those which he must, refer and even the brand name of the medication he can prescribe. He cannot refuse to see any patient, his compensation is not related in any way to the number of the patients he sees or the services he performs for them and he has no input at all into what fee, if any, the patient will be charged.
Following the July 14 examination of Lohr, Dr. Larsen prescribed birth control pills for her. On August 18, Dr. Larsen examined Lohr a second time after she called the clinic to report that she had discovered a lump in her right breast. Dr. Larsen recommended that Lohr discontinue drinking fluids containing caffeine, and that she "do self examinations for one to two months to see if the lump changed." However, he did not order or recommend a mammogram or a needle biopsy of the lump, either then or two months later, when Lohr reported to him on October 27 that she still had the lump in her breast.
On December 7, after Lohr reported that the lump had grown in size and hardened, Dr. Larsen again examined her and noted that the lump was "definitely suspicious." His notes also stated, "refer to a general surgeon ASAP." Lohr alleges that Dr. Larsen did not advise her that the matter was urgent.
When a general surgeon examined Lohr on January 5, 1989, he noted a much larger lump than was recorded in Dr. Larsen's notes of his December 7 examination. Two mastectomies were later performed on Lohr, one on February 20 and a second on March 27. The first operation confirmed that Lohr "had a stage II infiltrating ductal adenocarcinoma with intralymphatic tumor and vascular invasion." Since that time, Lohr has undergone chemotherapy and "remains at high risk for recurrence of her carcinoma."
Lohr claims that Dr. Larsen's plea of sovereign immunity should be denied because his function was similar to that of medical school faculty member-physicians who were denied sovereign immunity from claims of ordinary negligence asserted by their private patients in James v. Jane, 221 Va. 43, 282 S.E.2d 864 (1980). James established the test we use in determining government employees' claims of immunity in the following language:
[W]e examine the function [the] employee was performing and the extent of the state's interest and involvement in that function. Whether the act performed involves the use of judgment and discretion is a consideration, but it is not always determinative. . Of equal importance is the degree of control and direction exercised by the state over the employee whose negligence is involved.
We will apply the James test in this case.
Employee's Function — Commonwealth's Interest and Involvement Therein
In James, we indicated that if the function that a government employee was negligently performing was essential to a governmental objective and the government had a great interest and involvement in that function, those factors would weigh in favor of the employee's claim of sovereign immunity. Id. at 53-54, 282 S.E.2d at 869. On the other hand, if that function has only a marginal influence upon a governmental objective, and the government's interest and involvement in that function are "slight," these factors weigh against granting governmental immunity to a government employee. Id. at 54, 282 S.E.2d at 870.
The James defendants had private and staff patients and were "under no obligation to accept any individual" as a patient. 221 Va. at 47, 282 S.E.2d at 866. Although these physicians received no direct benefit from the fees that their private patients paid for their services, they indirectly benefitted from those fees because the fees were used in operating the medical school, which paid the physicians' salaries, and in funding a portion of their retirement benefits. Id. at 48, 282 S.E.2d at 866. The physicians in James were also authorized to compromise or forgive their charges to patients. Id. at 49, 282 S.E.2d at 866.
In James, "the paramount interest of the Commonwealth of Virginia [was] that the University of Virginia operate a good medical school and that it be staffed with efficient and competent administrators and professors." Id. at 54, 282 S.E.2d at 870. But the allegedly negligent acts of the James physicians were not undertaken in furtherance of the Commonwealth's interest in providing medical education. And we indicated that although the Commonwealth had the same interest and concern in treatment of the private patients in James which it had in the treatment of every patient treated in the Commonwealth, the Commonwealth's interest and control over the James physicians was "slight." Id. In later cases, we characterized the function of those physicians as that of "independent contractors," Messina v. Burden, 228 Va. 301, 313, 321 S.E.2d 657, 663 (1984), and "essentially private practitioners," Bowers v. Commonwealth, 225 Va. 245, 252, 302 S.E.2d 511, 515 (1983).
In contrast to James, the trial court found that Dr. Larsen could neither choose his patients nor forgive any part of the fees fixed by the clinic for his services. And the other evidence indicated that Dr. Larsen's salary and retirement benefits had no relation to fees paid by persons who received clinic services. The Commonwealth's much greater interest and involvement in Dr. Larsen's function is evident from the court's finding from the evidence that "the Commonwealth is attempting to provide quality medical care in certain specified areas for citizens of this State who are economically unable to acquire those services in the private sector."
And the trial court quoted the General Assembly's description of the purposes of its overall health program, of which the clinic's family planning program was a part, in the following pertinent language, ' 'the protection, improvement and preservation of the public health and of the environment are essential to the general welfare of the citizens of the Commonwealth." Code § 32.1-2 (emphasis added in the trial court's quotation). Furthermore, the trial court concluded that these health care services could not be delivered without using skilled physicians.
We conclude the trial court correctly held that at the time he was treating Lohr, Dr. Larsen was performing a function which was an essential part of the clinic's delivery of its health care services. The clinic's program in turn plays an integral role in the Commonwealth's objective of "the protection, improvement and preservation of the public health [which is] essential to the general welfare of the citizens of the Commonwealth."
Dr. Larsen's Use of Judgment and Discretion
To facilitate the efficient and effective operation of government, the exercise of the discretion vested in government employees should not be affected by threats of personal liability arising from the use of such discretion. Messina, 228 Va. at 308, 321 S.E.2d at 661. And because a government employee is liable for negligence in performing a ministerial act, see First Virginia Bank-Colonial v. Baker, 225 Va. 72, 78, 301 S.E.2d 8, 11 (1983), a government employee's use of judgment and discretion is an element in determining the issue of immunity. A necessary part of an immunity analysis is the level of discretion required of a government employee in performing his job and whether the employee is exercising that discretion in the discharge of his duties when the allegedly negligent act occurred.
However, as we pointed out in James, the use of judgment and discretion "is not always determinative." 221 Va. at 53, 282 S.E.2d at 869. Thus, because the broad discretion vested in the physicians in James was not attendant to actions that were integral to the Commonwealth's interest or function, there was no immunity. In this case, however, as we have pointed out, the exercise of discretion by Dr. Larsen was an integral part of the Commonwealth's health care program.
Lohr recognizes that if a broad discretion is vested in a government employee in performing the function complained of, as all parties recognize was the case with Dr. Larsen, it will weigh heavily in favor of a government employee's claim of immunity. But Lohr distinguishes discretionary medical decisions from discretionary governmental "policymaking" decisions.
We have not limited the element of discretion in determining governmental immunity to governmental policymakers; it has been extended to a state-employed physician, as was Dr. Larsen, Gargiulo v. Ohar, 239 Va. 209, 215, 387 S.E.2d 787, 791 (1990); a police officer in vehicular pursuit, Colby v. Boyden, 241 Va. 125, 130, 400 S.E.2d 184, 187 (1991); a high school teacher, Lentz v. Morris, 236 Va. 78, 83, 372 S.E.2d 608, 611 (1988); city- and state-employed maintenance supervisors, Messina, 228 Va. at 311, 313, 321 S.E.2d at 662, 664; and a state highway resident engineer, Bowers, 225 Va. at 253, 302 S.E.2d at 515; and a state-employed surgical intern, Lawhorne v. Harlan, 214 Va. 405, 407, 200 S.E.2d 569, 572 (1973). As we said in Colby, "[o]ur resolution [of the issue of sovereign immunity] . . . goes beyond determining whether the act constitutes the formulation or execution of policy." 241 Va. at 129, 400 S.E.2d at 186.
Commonwealth's Control and Direction of Dr. Larsen
The extent of a government's control and direction of its employee also influences our consideration of that employee's claim of immunity. A high level of control weighs in favor of immunity; a low level of such control weighs against immunity. James, 221 Va. at 53-54, 282 S.E.2d at 269.
At first glance, the issue of wide discretion that influences our consideration of the grant of governmental immunity in applying the third element of the James test appears to be at odds with our consideration of a higher level of governmental control in the application of the fourth element of that test in this case. However, when a government employee is specially trained to make discretionary decisions, the government's control must necessarily be limited in order to make maximum use of the employee's special training and subsequent experience.
There can be little doubt that the Commonwealth's direction and control of Dr. Larsen was far greater than its control of the physicians in James. Those physicians "exercise[d] broad discretion in selecting the methods by which they care[d] for [their patients]." James, 221 Va. at 48, 282 S.E.2d at 866. Here, the trial court has found that the Commonwealth controls "absolutely" the equipment Dr. Larsen used, the procedures he could perform and "even the brand names of the medication he [could] prescribe." Furthermore, the James physicians could decline to accept a particular person as a patient; Dr. Larson could not.
In sum, we conclude that Dr. Larsen satisfies all the elements of the James test for application of the doctrine of sovereign immunity. Accordingly, the judgment of the trial court will be
Affirmed.
In 1981, the Commonwealth abrogated its own immunity from tort liability for acts of simple negligence performed by its employees acting within the scope of their employment, but specifically preserved the immunities enjoyed by state employees. Code § 8.01-195.3.
Lohr attempts to limit the doctrine of sovereign immunity to those instances in which specially trained state employees follow "state-established rules," "state-prescribed methods," or "state-standardized procedures." It is true that we noted these factors as considerations in concluding that the necessary control element of the James test was present in Gargiulo, 239 Va. at 215, 387 S.E.2d at 791, but we did not indicate that such constraints were required to establish the necessary governmental control over a state employee who is a professional.