Case Name: Ilyaas GILBERT, et al., Appellants, v. Menachem MIODOVNIK, et al., Appellees
Court: District of Columbia Court of Appeals
Jurisdiction: District of Columbia
Decision Date: 2010-03-18
Citations: 990 A.2d 983
Docket Number: No. 07-CV-315
Parties: Ilyaas GILBERT, et al., Appellants, v. Menachem MIODOVNIK, et al., Appellees.
Judges: Before RUIZ, FISHER, and THOMPSON, Associate Judges.
Reporter: West's Atlantic Reporter, Second Series
Volume: 990
Pages: 983–1015

Head Matter:
Ilyaas GILBERT, et al., Appellants, v. Menachem MIODOVNIK, et al., Appellees.
No. 07-CV-315.
District of Columbia Court of Appeals.
Argued Sept. 17, 2008.
Decided March 18, 2010.
Wayne M. Willoughby, with whom Zev T. Gershon and Robin R. Smith, Owings Mills, MD, were on the brief, for appellants.
Donald L. DeVries, Jr., with whom Kelly Hughes Iverson and K. Nichole Nesbitt, Baltimore, MD, were on the brief, for ap-pellees.
Susan M. Jenkins and Joanna M. King filed a brief amici curiae for the American College of Nurse-Midwives and the American Association of Birth Centers in support of appellees.
Before RUIZ, FISHER, and THOMPSON, Associate Judges.

Opinion:
FISHER, Associate Judge:
Appellants Saara Abdul-Haqq and Michael Gilbert brought this medical malpractice action on behalf of themselves and their minor son, Ilyaas Gilbert, who suffered severe injuries at the time of his birth. They claim that Dr. Menachem Miodovnik, an employee of the Washington Hospital Center ("WHC"), was negligent because he did not intervene to alter the treatment plan the District of Columbia Birth Center ("DCBC"), an association of nurse-midwives, had developed for assisting the birth. Dr. Miodovnik, who never met or examined Mrs. Abdul-Haqq, discussed her care with a registered nurse-midwife from the DCBC on one occasion. The trial court held that Dr. Miodovnik did not owe a duty of care to the patient and granted summary judgment in favor of the appellees. We affirm.
I. Factual Summary
A.Mrs. Abdul-Haqq's Medical History
In September 2004, acting upon the advice of women at her mosque, Saara Abdul-Haqq sought prenatal care from the District of Columbia Birth Center. Mrs. Abdul-Haqq was pregnant with her third child, she was in normal health at the time, and she understood that all of her prenatal care would be provided by the nurse-midwives at the DCBC.
Mrs. Abdul-Haqq had delivered her two older children via cesarean section, but she wanted to attempt a vaginal birth of her third child. The medical profession refers to this procedure as a vaginal birth after cesarean section ("VBAC"). In the course of the treatment she received from the DCBC, Mrs. Abdul-Haqq was advised of the increased risks that a VBAC posed to herself and her fetus. In October 2004 Mrs. Abdul-Haqq signed a consent form which, among other things, identified tearing of the uterus as a risk associated with a VBAC, and indicated that this risk increased if the patient had had more than one cesarean section.
B.The Nurse-Midwives at the DCBC
The nurse-midwives of the DCBC provide health care services to women throughout the birth process, whether they deliver their babies at the Birth Center or in a hospital. When the DCBC manages a client's care, but birth center delivery is deemed inappropriate, the nurse-midwives make arrangements for hospital delivery. The DCBC nurse-midwives regularly assist women attempting a VBAC, and when they do so, the delivery occurs at the Washington Hospital Center.
C.Dr. Miodovnik and the DCBC
Pursuant to a one-page Memorandum of Understanding ("MOU"), Dr. Menachem Miodovnik, the Chief of Obstetrics and Gynecology at Washington Hospital Center Corporation, served as the Director of Medical Affairs of the DCBC. This title is somewhat misleading, however. Under the DCBC Policies and Practice Guidelines, nurse-midwives do not report to the Director of Medical Affairs; they report to the Director of Clinical Services of the DCBC, and the Director of Clinical Services reports to the President and CEO of the DCBC.
As provided in a separate one-page MOU, Dr. Miodovnik also served as a consulting obstetrician for the DCBC. Dr. Miodovnik agreed to interact with the nurse-midwives in various ways that ranged from evaluating patient records to "accepting] the transfer and medical management" of patients who developed complications. If a transfer to medical management becomes necessary, DCBC clients have the option of choosing their own physician or using the DCBC's consultant or his designee.
D.The Chart Review
On March 21, 2005, Nurse-Midwife Alexander discussed Mrs. Abdul-Haqq's case with Dr. Miodovnik during a routine "chart review" of several patients. According to Dr. Miodovnik, during such routine reviews, he does not actually examine the medical charts of the patients. Instead, the nurse-midwives present the cases and he writes notes.
In this instance, Dr. Miodovnik did not examine Mrs. Abdul-Haqq's chart. Prior to the chart review, Nurse-Midwife Alexander reviewed Mrs. Abdul-Haqq's medical records and recorded pertinent information on a form which she brought to her meeting with Dr. Miodovnik. In addition to sharing the information on the form, Nurse-Midwife Alexander told Dr. Mio-dovnik that Mrs. Abdul-Haqq "desired a VBAC, that she wanted — very much wanted to have a vaginal birth." According to Nurse-Midwife Alexander, Dr. Miodovnik expressed concern about the increased risks associated with a VBAC after two prior cesarean sections and advised her to reiterate the risks of the procedure to Mrs. Abdul-Haqq. She testified: "I remember that the patient really wanted a VBAC. He [Dr. Miodovnik] really wanted us to be sure to reiterate the risk to the patient and asked if she had been properly consented and that we do so again." Nurse-Midwife Alexander resisted the suggestion that Dr. Miodovnik had "approved a VBAC for this patient.... [H]e was not happy that this patient wanted a VBAC."
Dr. Miodovnik made an entry on the form (later inserted into Mrs. Abdul-Haqq's file) which stated "P @ 35/7 weeks gestation. H/O c/s x 2. Pt. Desires VBAC. Pt. understand [sic] that the risk of VBAC after two cesarean section [sic] is much higher for uterine rupture — fetal death and risk for having increased morbidity for herself. Needs prophylactic antibiotics in labor."
E.Mrs. Abdul-Haqq's Treatment After the Chart Review
According to her deposition testimony, Nurse-Midwife Alexander intended to tell Mrs. Abdul-Haqq — "like Dr. Miodovnik told [her] to do" — that she had a higher risk of uterine rupture than other patients. So far as the evidence discloses, however, after the chart review none of the nurse-midwives reiterated to Mrs. Abdul-Haqq the risks of a VBAC after two prior cesarean sections.
After this "chart review" session, the nurse-midwives did not update Dr. Mio-dovnik about Mrs. Abdul-Haqq's care, and he did not inquire about her treatment. The doctor never met Mrs. Abdul-Haqq, nor did he ever examine her. Mrs. Abdul-Haqq did not know that a chart review had taken place, and she was not aware of Dr. Miodovnik's existence. Up until the time of her delivery, Mrs. Abdul-Haqq did not know that her treatment had been discussed with anyone other than the nurse-midwives at the DCBC.
F.Mrs. Abdul-Haqq's Labor and Delivery
On April 26, 2005, Mrs. Abdul-Haqq went to Washington Hospital Center because she thought she was in labor. At that time, she was still under the care of the DCBC nurse-midwives, and a VBAC at the hospital attended by a nurse-midwife was still planned. She was monitored and discharged. That night, Mrs. Abdul-Haqq returned to the hospital and was placed in the care of Nurse-Midwife Mairi Roth-man.
Following standard procedure, Nurse-Midwife Rothman notified the backup physician, Virginia Leslie, that one of the DCBC's patients was in labor. Nurse- Midwife Rothman presented the patient's medical history to Dr. Leslie, who expressed concern about the plan for delivery. As a result of this conversation, Dr. Leslie advised Mrs. Abdul-Haqq of the risks associated with attempting a VBAC and recommended a third cesarean section. Mrs. Abdul-Haqq consented, and the hospital staff began preparing for surgery.
Before the operating room was ready, however, the fetal heart monitor indicated that the baby's heart rate was rising, and then the hospital staff began having trouble detecting the heartbeat. Surgery began, and "[u]pon entry into the abdomen and visualization of the uterus, it was clear" that Mrs. Abdul-Haqq's uterus had ruptured. In the early morning of April 27, 2005, Ilyaas Gilbert was delivered through the rupture in Mrs. Abdul-Haqq's uterus. He sustained brain damage and other severe and permanent injuries.
II. Procedural Background
On September 21, 2005, appellants filed a complaint accusing the DCBC, Dr. Mio-dovnik, and WHC of negligence. Dr. Miodovnik and Washington Hospital Center moved for summary judgment, arguing that the plaintiffs' claim of negligence failed because "Dr. Miodovnik owed no duty of care to Saara Abdul-Haqq." Plaintiffs responded, asserting that Dr. Miodovnik "collaborated on developing and approving a treatment plan" that involved an attempt at a VBAC, and that this was a violation of the standard of care.
The Superior Court issued an opinion and order on January 11, 2007, granting the motion of defendants Miodovnik and WHC for summary judgment. After noting that "a review of binding authority on this court has revealed woefully little applicable law to answer the question of when a duty exists between a consulting physician and a patient," the trial court examined the facts of the instant case in light of the decision in Newborn v. United States, 238 F.Supp.2d 145 (D.D.C.2002). The court noted, among other factors, that Dr. Miodovnik never met Mrs. Abdul-Haqq; she was unaware of Dr. Mio-dovnik's existence; "Dr. Miodovnik only considered and commented on plaintiffs medical care on one occasion"; the nurse-midwives were qualified to exercise independent judgment; and Dr. Miodovnik was not paid for the chart review. In light of these factors, the trial court concluded that Dr. Miodovnik's chart review with Nurse-Midwife Alexander "was insufficient to create a duty vis-a-vis plaintiff Abdul-Haqq."
The court noted that its legal conclusion was supported by public policy considerations. Imposing liability on a consulting physician under these circumstances would discourage consultation between health care providers. "Here, the District has seen fit under its regulations to allow nurse-midwives to provide standard primary care for pregnant women, without the aid of a doctor. Encouraging the nurse-midwives to consult with obstetrics professionals is in the public interest. Conversely, extending liability to such consultations, without more, contradicts that interest. The court is unprepared to do this."
The appellants later entered into a settlement with the DCBC. This appeal followed.
III. Standard of Review
We review orders granting summary judgment de novo. See Williams v. District of Columbia, 902 A.2d 91, 94 (D.C.2006). When doing so, we independently analyze the record in the light most favorable to the non-moving party, drawing all reasonable inferences from the evidence in the non-moving party's favor. See generally EastBanc, Inc. v. Georgetown Park Assocs. II, L.P., 940 A.2d 996, 1001-02 (D.C.2008); Nat'l Ass'n of Postmasters of the United States v. Hyatt Regency Washington, 894 A.2d 471, 474 (D.C.2006). Summary judgment is appropriate where "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Super. Ct. Civ. R. 56(c).
The party moving for summary judgment bears the initial burden of establishing that there is no genuine issue of material fact, and then the burden shifts to the non-moving party to identify specific facts demonstrating a genuine issue for resolution at trial. See LaPrade v. Rosinsky, 882 A.2d 192, 196 (D.C.2005). To satisfy this burden, the non-moving party must show more than a "metaphysical doubt" or a "scintilla of evidence." Id. "[T]here must be some significant probative evidence tending to support the complaint so that a reasonable fact-finder could return a verdict for the non-moving party." Warren v. Medlantic Health Group, Inc., 936 A.2d 733, 737 (D.C.2007) (citations and punctuation omitted).
In order to defeat a properly-supported motion for summary judgment in an action for medical malpractice, the plaintiff must present a prima facie case establishing the applicable standard of care, showing that the standard of care has been violated, and demonstrating a causal connection between the violation and the damage suffered. See Warren v. Medlantic Health, 936 A.2d at 737; Derzavis v. Bepko, 766 A.2d 514, 519 (D.C.2000); Ferrell v. Rosenbaum, 691 A.2d 641, 646 (D.C.1997). Of course, this abbreviated statement of the elements of proof assumes that the defendant owes the plaintiff a duty of care. "The foundation of modern negligence law is the existence of a duty owed by the defendant to the plaintiff. Negligence is a breach of duty; if there is no duty, there can be no breach, and hence no negligence." N.O.L. v. District of Columbia, 674 A.2d 498, 499 n. 2 (D.C.1996). Accord, Youssef v. 3636 Corp., 777 A.2d 787, 792 (D.C.2001) ("[A] defendant is liable to a plaintiff for negligence only when the defendant owes the plaintiff some duty of care.").
IV. Statutes, Regulations, and Professional Standards Governing Midwifery in the District of Columbia
The Council of the District of Columbia has recognized the independence of nurse- midwives, and their practice is governed by statutes and regulations. Nurse-midwives are considered to be engaged in advanced practice registered nursing. D.C.Code § 3-1202.04(b)(l) (2001) ("Advanced practice registered nursing includes, but is not limited to, the categories of nurse midwife_"). Advanced practice registered nurses "may perform actions of nursing diagnosis and nursing treatment of alterations of the health status"; they "may also perform actions of medical diagnosis and treatment" if they are "carried out in accordance with the procedures required by this chapter[,]" D.C.Code § 3-1201.02(2) (2001), and they may "[m]ake referrals for appropriate therapies or treatments[.]" D.C.Code § 3-1206.04(3) (2001).
Advanced practice registered nurses may also obtain clinical and admitting privileges at hospitals. "No provision of District of Columbia law, institutional or staff bylaw of a facility or agency, rule or regulation, or practice shall prohibit qualified advanced practice registered nurses, podiatrists, or psychologists from being accorded clinical privileges and appointed to all categories of staff membership at those facilities and agencies that offer the kinds of services that can be performed by either members of these health professions or physicians." D.C.Code § 44-507(c) (2001).
District of Columbia Municipal Regulations elaborate on the role of nurse-midwives and the scope of their practice. A certified nurse-midwife is "a registered nurse trained in an educational program to provide nurse-midwifery services, exercise independent judgment, and assume primary responsibility for the care of patients." 17 DCMR § 5899.1 (2002). "[W]hen functioning within the authorized scope of practice," certified nurse-midwives "are qualified to assume primary responsibility for the care of their patients" through "the use of independent judgment as well as collaborative interaction with physicians or osteopaths." 17 DCMR § 5800.1 (2002). The scope of their practice includes providing primary health care and managing the "care of the normal obstetrical patient," who is defined as "a healthy individual who meets the criteria established in practice protocols as normal." See 17 DCMR § 5808.1(a) and Cj) (2002); 17 DCMR § 5808.6 (1989). Nurse-midwives may "[mjanage the normal obstetrical patient during labor and delivery to include amniotomy, episiotomy, and repair," 17 DCMR § 5808.1(c) (2002), but they "may not perform a cesarean section or surgical abortion." 17 DCMR § 5808.5 (1989).
Nurse-midwives play an important role in providing health care. Amici inform us that, in 2005, 11.2% of all vaginal births in the United States were attended by nurse-midwives. See Joyce A. MaRtin, et al., BiRths: Final Data for 2005, National Center For Health Statistios, Vital Health Stat Series Vol. 56 No. 6, at 18 (2007). Most births attended by nurse-midwives occurred in hospitals. Id. The majority of women attended by nurse-midwives live in under-served communities, see Jeanne Raisler & Holly Kennedy, Midwifery Care of Poor and Vulnerable Women: 1925-2003, 50 J. Midwifery & W.H. 120 (2005), and these women report high levels of satisfaction. See Amerioan College of Nurse-Midwives, Midwifery in 2007: Evidence-Based PRACTICE (2007).
V. The Asserted Duty and Its Potential Bases
The trial court held that appellants failed to establish the first element of medical malpractice — that Dr. Miodovnik had a duty to Mrs. Abdul-Haqq. Whether a physician owed a duty to a patient in a particular set of circumstances is a question of law to be determined by the court, although the answer depends on the totality of the circumstances in each individual case. See Childs v. Purll, 882 A.2d 227, 233 (D.C.2005); Croce v. Hall, 657 A.2d 307, 310 (D.C.1995). "The existence of a duty . results ultimately from policy decisions made by the courts and the legislatures." Williams v. Baker, 572 A.2d 1062, 1064 (D.C.1990) (en banc). See District of Columbia v. Cooper, 483 A.2d 317, 321 (D.C.1984) (noting that the existence of a duty of care is " 'essentially a question of whether the policy of the law will extend the responsibility for the conduct to the consequences which have in fact occurred' ") (citations omitted). The legislature has not spoken directly to the issue before us now, but its decision to recognize the professional status of nurse-midwives necessarily informs our analysis.
The issue of whether a consulting physician owes a duty of care to a patient arises in a variety of circumstances. Nevertheless, in resolving this appeal, we do not consider it either necessary or helpful to address broad questions of duty in the abstract. "[A]s a general rule, this court will decide only such questions as are necessary for a determination of the case presented for consideration, and will not render decisions in advance of such necessity." District of Columbia v. Wical Ltd. P'ship, 630 A.2d 174, 182 (D.C.1993) (quoting Johnson v. Morris, 87 Wash.2d 922, 931, 557 P.2d 1299, 1305 (1976) (en banc)). Rather, we consider whether Dr. Miodov-nik had a duty of the type at issue here.
We assume, without deciding, that Dr. Miodovnik had a duty to use reasonable care when conferring with the nurse-midwives from DCBC, and that in some circumstances this duty would extend to the patient. However, there is no evidence that he gave bad advice or failed to identify any material risks of which Nurse-Midwife Alexander was not aware. According to Nurse-Midwife Alexander, Dr. Miodov-nik expressed his concern about the wisdom of attempting a VBAC after two prior cesarean sections ("he was not happy that this patient wanted a VBAC") and advised her to reiterate the risks to Mrs. Abdul-Haqq. There is no evidence to the contrary.
Appellants argue here that Dr. Miodov-nik was negligent because he "failed to order a pre-labor cesarean section for Mrs. Abdul-Haqq and instead signed off on a treatment plan calling for a VBAC." Of course, Dr. Miodovnik could not "order" surgery without the patient's consent. See In re A.C., 573 A.2d 1235 (D.C.1990) (en banc). We understand appellants' argument to mean that Dr. Miodovnik had a duty (1) to override the judgment of the nurse-midwives and alter the plan of treatment, and (2) to communicate with Mrs. Abdul-Haqq directly and counsel her that an attempt at a VBAC was inadvisable.
A. Was There a Physician-Patient Relationship?
The undisputed facts demonstrate that Mrs. Abdul-Haqq never met or knew of Dr. Miodovnik. The doctor never examined Mrs. Abdul-Haqq, nor did he independently review or analyze her medical records. Nurse-Midwife Alexander discussed Mrs. Abdul-Haqq's treatment with Dr. Miodovnik on only one occasion. The doctor highlighted the risks presented by the planned course of treatment. Nurse-Midwife Alexander, the treating health care provider, did not ask Dr. Miodovnik to take over any aspect of Mrs. Abdul-Haqq's care, and he did not do so. When interacting with her patient, Nurse-Midwife Alexander did not attribute a medical opinion to Dr. Miodovnik. Indeed, she did not even inform Mrs. Abdul-Haqq that a doctor had been consulted. These facts demonstrate as a matter of law that there was no traditional physician-patient relationship between Dr. Miodovnik and Mrs. Abdul-Haqq that could have given rise to a duty to intervene. See generally Hankerson v. Thomas, 148 A.2d 583, 584 (D.C.1959) ("The relation of physician and pa tient is a consensual one depending on the physician's acceptance of the patient and the latter's assent to the medical services."); Dehn v. Edgecombe, 384 Md. 606, 865 A.2d 603, 611 (2005) ("What is important . is that the relationship is a consensual one, and when no prior relationship exists, the physician must take some action to treat the person before the physician-patient relationship can be established."); Dodd-Anderson v. Henderson, 107 F.3d 20, 1997 WL 60743, at *2 (10th Cir.1997) (unpublished) ("[T]he minimal involvement Dr. Henderson had with this patient did not raise a genuine issue as to whether Dr. Henderson's acts established a traditional doctor-patient relationship.").
B. Did the Asserted Duty Arise out of Dr. Miodovnik's Role as Consulting Physician?
Nor did Dr. Miodovnik acquire a duty to order a pre-labor cesarean section for Mrs. Abdul-Haqq or to counsel her directly either because of his relationship with the DCBC or by virtue of his participation in the chart review.
1. The Formal Relationship Between the DCBC and Dr. Miodovnik
The DCBC did enter into agreements with Dr. Miodovnik, but the existence of this formal relationship does not mean that every interaction between the nurse-midwives and the doctor was a "formal consultation," as that term is used by medical professionals. Moreover, nothing in those MOUs either authorized or obligated Dr. Miodovnik to usurp control over the care and treatment of DCBC clients. Although Dr. Miodovnik arguably had a contractual duty to the DCBC to be available to accept the transfer of a patient's care (or to designate another obstetrician who would do so), the nurse-midwives did not ask him to take a more active role in Mrs. Abdul-Haqq's treatment. See In re Sealed Case, 314 U.S.App. D.C. 271, 274, 67 F.3d 965, 968 (1995) ("[A]ny duty owed by the defendant Consultant in the circumstances of this case was limited to a careful review of the laboratory records referred to him by Mr. B's primary physician.").
The DCBC and Dr. Miodovnik agreed to develop a system for "medical consultation and backup OB/GYN services." As occurs when other health care practitioners cooperate, the MOUs contemplated that interaction between Dr. Miodovnik and the nurse-midwives at the DCBC would range across a spectrum. The MOUs mention "consultation," "review and evaluation of specific client medical records," "working] in collaboration and/or under medical direction when complications arise," and "accepting] and/or delegating] responsibility for medical [management] and/or co-management of complicated clients." The MOUs did not establish a duty for Dr. Miodovnik to intervene without request in the care and treatment of DCBC patients. See In re Sealed Case, 314 U.S.App. D.C. at 276, 67 F.3d at 970 (concluding as a matter of law that the standard of care owed by the consulting physician extended "only to the careful performance of the duties outlined by the contractual agreement"); Dodd-Anderson v. Stevens, 905 F.Supp. 937, 949 (D. Kansas 1995) ("The extent of the undertaking defines the scope of the duty and a defendant cannot be held liable for the negligent performance of a task which he or she did not agree to assume."), aff'd, 107 F.3d 20 (10th Cir.1997) (unpublished).
2. The Effect of Consultation
In some circumstances courts have held that, even in the absence of a formal arrangement, the fact that consultation has occurred may create a duty to the patient. See Diggs v. Arizona Cardiologists, Ltd., 198 Ariz. 198, 8 P.3d 386, 390 (App.2000) (consulting cardiologist owed a duty of care to patient where emergency room physician lacked "the expertise to interpret the echocardiogram"); Cogswell v. Chapman, 249 A.D.2d 865, 672 N.Y.S.2d 460, 462 (1998) (taking into account the totality of the record, there was a factual question whether the consultant had a duty to the patient "especially in light of [his] expertise in the field" and the emergency room physician's lack of expertise). Other courts that have addressed the issue have found that a consultation with a treating physician did not give rise to a duty. See Bessenyei v. Raiti, 266 F.Supp.2d 408, 413 (D.Md.2003) (consulting physician had no duty where he discussed the case with an emergency room doctor "of comparable ability and competence to handle the situation" who retained "decision-making authority over plaintiffs course of treatment"); Schrader v. Kohout, 239 Ga.App. 134, 522 S.E.2d 19, 22 (1999) (factual record did not reveal "acceptance of direct responsibility and control"); Hill v. Kokosky, 186 Mich.App. 300, 463 N.W.2d 265, 268 (1990) (consulting physician had no duty where the treating practitioners "were not under his direction or control"). These decisions are context-specific and do not establish a general rule.
Appellants rely heavily upon Diggs, where Dr. Valdez, a cardiologist, briefly consulted with Dr. Johnson, an emergency room physician. He reviewed the results of an electrocardiogram (EKG) and an echocardiogram and agreed that the patient was suffering from pericarditis rather than a myocardial infarction. The court emphasized that the cardiologist voluntarily provided his expertise to the emergency room physician, knowing that it was necessary for the protection of the patient and that the other doctor would rely on it. 8 P.3d at 390. "Dr. Johnson was not free to accept or reject Dr. Valdez's advice. Dr. Johnson was not a cardiologist; he needed the specialized knowledge of someone such as Dr. Valdez to read the echocardiogram and to confirm his interpretation of [the patient's] EKG." Id. at 391. Moreover, "Dr. Valdez admitted that his advice significantly affected [the patient's] treatment." Id. Under these circumstances, the court held that the cardiologist owed a duty of care although he had never seen the patient.
Analogizing to Diggs and similar cases involving medical diagnosis, appellants argue that Dr. Miodovnik had a duty to intervene because he was a doctor specializing in obstetrics and therefore had superior knowledge and skill. We disagree. With respect to the skills relevant here, Dr. Miodovnik was a peer of Nurse-Midwife Alexander, not her superior. The nurse-midwives at the DCBC were independent practitioners fully qualified to act in these circumstances. While it is true that, as between Dr. Miodovnik and Nurse-Midwife Alexander, only the doctor was qualified to perform a cesarean section, she was no less qualified than he to speak with the patient and arrange for the surgery. Nor was Dr. Miodovnik uniquely competent to discuss the risks of a VBAC with Mrs. Abdul-Haqq. He was entitled to rely upon Nurse-Midwife Alexander to discuss those risks with her own patient. See Fowerbaugh v. University Hosps., 118 Ohio App.3d 402, 692 N.E.2d 1091, 1094 (1997) ("None of the cases [cited] provides that consulting physicians have an absolute duty to communicate their findings to the patient directly, either orally or in writing.").
Nor did Dr. Miodovnik have a duty to override the nurse-midwife's plan of care. The record establishes that Dr. Miodov-nik's role was, and was intended to be, limited in scope. He did not become in practical terms the ultimate decision-maker determining the course of Mrs. Abdul-Haqq's treatment. See Newborn v. United States, 238 F.Supp.2d 145, 149-50 (D.D.C.2002) (finding no duty where the consulting doctor did not play a supervisory role, the treating practitioner maintained independent judgment, and the consulting physician "did not provide the extensive and continuous type of consultation that made her practically the ultimate decisionmaker in [the patient's] treatment"), aff'd, 84 Fed.Appx. 97, 98 (D.C.Cir.2003) (noting that the undisputed facts "fail to indicate the consulting physician's brief exchanges with the primary care provider were anything but mere suggestions").
It is possible that if Dr. Miodovnik had insisted that the nurse-midwives schedule a cesarean section, they would have done so, but the possibility that he could have prevented this tragedy did not create a duty for him to intervene. See Feirson v. District of Columbia, 362 F.Supp.2d 244, 252 (D.D.C.2005) ("[T]here is no genuine issue of material fact as to whether the contract between PFC [a private professional health organization] and the District created an affirmative duty on the part of the physician defendants to protect Sgt. Feirson." (applying Restatement (Seoond) of Torts § 314)); see also Bessenyei, 266 F.Supp.2d at 412-13 (declining to regard the consulting doctor as a joint provider of medical services although he acknowledged knowing that the treating practitioner would most likely consider his advice in making a decision; "an implication that one will be considering another's opinion in the decision-making process and a declaration that one is relying upon the advice being given to control the course of treatment are two very different things"). As discussed above, Dr. Miodovnik was entitled to rely upon the nurse-midwives of DCBC to reiterate the risks of a VBAC to their patient. There is no evidence in the record that the DCBC turned over Mrs. Abdul-Haqq's care to Dr. Miodovnik. See Newborn, 238 F.Supp.2d at 149 (concluding that the existence and nature of a consulting doctor's duty "depend[] upon the degree and frequency of her involvement with the patient's treatment. Substantial or frequent consultation that amounts to virtual supervision of a patient's treatment tends to give rise to a duty, whereas informal or occasional consultation does not.").
VI. There Was No Duty to Intervene
We have found the decision in Dodd-Anderson v. Stevens, 905 F.Supp. 937 (D. Kansas 1995), aff'd, Dodd-Anderson v. Henderson, 107 F.3d 20, 1997 WL 60743 (10th Cir.1997) (unpublished), to be helpful in analyzing whether there was a duty to intervene in circumstances like these. In that case, which also involved a newborn child, the Tenth Circuit rejected the argument that Dr. Henderson, the hospital's chief-of-staff, who had consulted with the baby's attending physician, had a duty to intervene and have the baby transferred more promptly to another facility better equipped to handle her needs. The court determined that (1) Dr. Henderson had insufficient contact with the patient to establish a doctor-patient relationship, (2) Dr. Henderson had no duty to force the attending physician to follow his advice, (3) there was no evidence that Dr. Henderson "was wrong" in informing the treating physician of his impressions based on his limited knowledge of the patient, (4) Dr. Henderson's duty was limited to the service he undertook, and (5) "whatever duties Dr. Henderson owed the parties were fulfilled." See 107 F.3d 20, 1997 WL 60743. The circuit court upheld the district court's ruling, "as a matter of law, that [Dr. Henderson] had no legal duty to 'take charge' of [the baby's] care and arrange for her immediate transfer to another hospital." Dodd-Anderson v. Stevens, 905 F.Supp. at 948, aff'd, Dodd-Anderson v. Henderson, 107 F.3d 20, 1997 WL 60743 (10th Cir.1997) (unpublished).
Similarly, Dr. Miodovnik did not have a duty to take charge of Mrs. Abdul-Haqq's treatment. See Dodd-Anderson v. Stevens, 905 F.Supp. at 948 (holding that "no reasonable person, applying contemporary standards, would recognize and agree that a physician has, or should have, a legal duty to unilaterally and perhaps forcibly override the medical judgment of another physician, particularly a treating physician. The list of adverse consequences to the medical community and to patients is obvious and endless . "), aff'd, 107 F.3d 20, 1997 WL 60743, at *2 (10th Cir.1997) (unpublished) (reporting that it had found no cases holding that "a physician who merely offers medical advice to an attending physician . has a duty to force the attending physician to follow that advice").
The decision in Wilson v. Athens-Limestone Hosp., 894 So.2d 630 (Ala.2004), addressed similar issues. Dr. Teng, a pediatrician who had a pre-existing physician-patient relationship with a child, learned that she was in the emergency room and briefly discussed her case with the emergency room doctor. 894 So.2d at 632. Dr. Teng did not treat or diagnose the child during her visit to the emergency room and did not prescribe any medication or give any medical advice on that occasion. Id. at 635. The emergency room doctors retained control over the child's treatment at all times during that visit. Id. Relying on the decision in Dodd-Anderson v. Stevens, the Supreme Court of Alabama held that Dr. Teng did not have a duty to intervene in the child's treatment by the emergency room doctor. Id.
Appellants do not cite a single comparable case in which a court imposed upon a doctor a duty to take over the care and treatment of the patient of an independent health care professional, without a request to do so. Nor do appellants cite any cases in which a court held that a doctor had a duty to inform another practitioner's patient of a risk or danger when the treating practitioner was available to do so.
Nurse-Midwife Alexander acknowledged that Dr. Miodovnik advised her to reiterate to Mrs. Abdul-Haqq the risks of attempting a VBAC after two cesarean sections. The DCBC nurse-midwives were fully competent to discuss these risks with Mrs. Abdul-Haqq and to convince her that a third cesarean section was necessary. This was not an emergency situation — at 35-37 weeks of gestation, Mrs. Abdul-Haqq was not due for another few weeks. There was ample time for Nurse-Midwife Alexander or one of her colleagues to ap proach Mrs. Abdul-Haqq, to discuss the risks, and to seek additional help if she was unable to convince the patient to undergo a cesarean section. Dr. Miodovnik did not have a duty to monitor the situation to make sure Nurse-Midwife Alexander fulfilled her obligation to Mrs. Abdul-Haqq.
VIL Conclusion
Under the circumstances of this case, we agree with the trial court's determination that Dr. Miodovnik had no duty to intervene in Mrs. Abdul-Haqq's care by ordering a cesarean section or by personally advising her not to attempt a VBAC. The judgment of the Superior Court is hereby
Affirmed.
. Because both pages are signed, it is not clear whether Dr. Miodovnik's agreements with the DCBC constitute one two-page MOU or two one-page MOUs. The answer to this question is irrelevant for our purposes.
. Appellants' claims against WHC are based on a theory of vicarious liability. Appellants do not allege independent grounds for liability against WHC.
. For example, Dr. Miodovnik testified that it was his understanding after the March 21, 2005, chart review, that a nurse-midwife would "instruct" Mrs. Abdul-Haqq to have a repeat cesarean section. He stated that he expected the nurse-midwife to call him or conduct another chart review with him if the patient continued to refuse a cesarean section. Dr. Miodovnik also testified that the practice then would have been to "send the patient to the high risk clinic for further consultation." Appellants challenge the veracity of this testimony. Because Dr. Miodovnik's deposition testimony expands somewhat on Nurse-Midwife Alexander's deposition testimony and the notation on Saara Abdul-Haqq's medical chart, we have omitted this portion of Dr. Miodovnik's testimony from our statement of facts and do not consider it in our analysis. The dissent faults us for ignoring this testimony, see post, note 5, but we have done so in order to construe the record in the light most favorable to appellants. Adding this disputed testimony to the mix would not change our analysis.
. We quote the versions of these statutes in effect at the time of these events.
. The questions of duty of care and standard of care are separate inquiries under our case law, but they often overlap. See Newborn v. United States, 238 F.Supp.2d 145, 149 (D.D.C.2002) (observing that the questions of duty of care and standard of care appear "merged'— or, perhaps, blurred — into a single question in the District of Columbia"), aff'd, 84 Fed.Appx. 97 (D.C.Cir.2003). Our medical malpractice cases may foster this impression because in many of them there was no dispute that the doctor owed a duty of care to his patient.
Appellants urge us to hold that Dr. Miodov-nik had an undefined duty of care toward Mrs. Abdul-Haqq (or at least that there are enough facts in dispute to preclude summary judgment), then to remand for a trial to identify a standard of care and to determine whether that standard was breached, but we decline to approach our analysis in that fashion. In many cases, especially those involving consultants, if a duty exists at all, it is limited in nature. See In re Sealed Case, 314 U.S.App. D.C. 271, 274, 67 F.3d 965, 968 (1995) ("[A]ny duty owed by the defendant Consultant in the circumstances of this case was limited to a careful review of the laboratory records referred to him by Mr. B's primary physician."). The crucial question in this case is whether Dr. Miodovnik had a duty to intervene in the care of Mrs. Abdul-Haqq.
. Cf. In re Sealed Case, 314 U.S.App. D.C. 271, 275, 67 F.3d 965, 969 (1995) ("Mrs. B does not allege that Consultant misread the six pages of results he reviewed, nor that he failed to inquire into or diagnose any underlying medical problem that he should have suspected based on those six pages."); Dodd-Anderson v. Henderson, 107 F.3d 20, 1997 WL 60743, at *3 (10th Cir.1997) (unpublished) ("Even if Dr. Henderson incurred some duty when he responded to the call of the respiratory therapist, it was only a duty to inform Dr. Stevens of his impressions based on his limited knowledge of the patient. This he did. There is no evidence that he was wrong in this regard.").
. Although appellants dispute a portion of Dr. Miodovnik's testimony about the chart review, see note 3, supra, they have not proffered any evidence to contradict the account of Nurse-Midwife Alexander.
. In July 2004, the American College of Obstetricians and Gynecologists ("ACOG") issued a Practice Bulletin entitled "Vaginal Birth After Previous Cesarean Delivery." The bulletin states, among other things, that "for women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor." American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 54: Vaginal Birth After Previous Cesarean Delivery (2004). In other words, "a trial of labor should not be attempted" if the patient has "[t]wo prior uterine scars and no vaginal deliveries." Id. Dr. Miodovnik acknowledged that "it's clearly said, by ACOG, that if you have two cesarean sections without vaginal delivery, it is contraindicated of VBAC."
. Courts disagree on whether a physician-patient relationship is a necessary element of a medical malpractice case. Some courts have held that even in the absence of a physician-patient relationship, a doctor may still have a duty of care in connection with his professional activities. See Diggs v. Arizona Cardiologists, Ltd., 198 Ariz. 198, 8 P.3d 386, 387 (App.2000) (holding that "an express physician-patient relationship is not a requisite for finding a duty of reasonable care"); Greenberg v. Perkins, 845 P.2d 530 (Colo.1993) (in the context of independent medical examinations, a duty may be imposed despite the lack of a physician-patient relationship). Other courts have held that there is no duty in the absence of a physician-patient relationship. See Wilson v. Athens-Limestone Hosp., 894 So.2d 630, 633 (Ala.2004) (liability for medical malpractice is based on the breach of a duty, which depends on the existence of a physician-patient relationship); McKinney v. Schlatter, 118 Ohio App.3d 328, 692 N.E.2d 1045, 1047 (1997) (holding that the existence of a duty "depends upon whether there was a physician-patient relationship"); Wheeler v. Yettie Kersting Mem'l Hosp., 866 S.W.2d 32, 38 (Tex.App.1993); Hill v. Kokosky, 186 Mich. App. 300, 463 N.W.2d 265, 266 (1990). In Newborn v. United States, 238 F.Supp.2d 145, 149 n. 2 (D.D.C.2002), the court opined that, under District of Columbia law, "the existence of a physician-patient relationship . is not one of the elements of negligence in cases against doctors." We have not found a case where this court has decided that issue, and we need not decide it here. In the next section we consider whether a duty arose even though a physician-patient relationship had not been established.
. In Hankerson we said that "[t]he existence of [a physician-patient] relationship is a question of fact." 148 A.2d at 584. That general statement does not preclude a grant of summary judgment in appropriate circumstances, however.
. Because it is an unpublished opinion of the Tenth Circuit, we consider the decision in Dodd-Anderson v. Henderson in light of that court's rules. Pursuant to Tenth Circuit Rule 32.1, "[u]npublished decisions are not prece-dential, but may be cited for their persuasive value." Consequently, we treat the decision in Dodd-Anderson v. Henderson as persuasive, not binding, authority (which, of course, is the same way we would treat the opinion if it were published).
. As Dr. Miodovnik explained: "A consultation, I see as myself talking to the patient. And I never talked to Ms. Abdul-Haqq." An opinion of the ACOG Committee on Ethics distinguishes between "professional dialogue" and a "formal consultation," which often includes an examination of the patient. American College of Obstetricians and Gynecologists, Committee on Ethics, Committee Opinion No. 365: Seeking and Giving Consultation (2007).
. If a transfer of care were required, Dr. Miodovnik would not necessarily treat the patient. The MOUs make clear that he could delegate responsibility to another doctor. Moreover, under the DCBC Policies and Practice Guidelines, "If an antepartum transfer to medical management is necessary, clients will have the option of choosing their own physician or use [sic] the DCBC's consultant."
. Nurse-midwives "practice within a health care system that provides for consultation, collaborative management, or referral, as indicated by the health status of the client." See American College of Nurse Midwives, Standards for the Practice of Midwifery (2003); see also American College of Obstetricians and Gynecologists, Committee on Ethics, Committee Opinion No. 365: Seeking and Giving Consultation (2007) (defining three levels of consultation: a single-visit consultation, continuing collaborative care, and transfer of primary clinical responsibility, and identifying "professional dialogue" as another, less formal, type of interaction).
. Diggs relied in part on Restatement (Second) of Torts § 324A, which the Arizona Court of Appeals had adopted. Restatement (Second) of Torts § 324A provides "One who undertakes, gratuitously or for consideration, to render services to another which he should recognize as necessary for the protection of a third person or his things, is subject to liability to the third person for physical harm resulting from his failure to exercise reasonable care to protect his undertaking if (a) his failure to exercise reasonable care increases the risks of such harm, or (b) he has undertaken to perform a duty owed by the other to the third person, or (c) the harm is suffered because of reliance of the other or the third person upon the undertaking." We have not adopted § 324A in this jurisdiction, but even if we were to do so, it would not apply here for several reasons: (1) Dr. Miodovnik did not, through his actions or inaction, leave Mrs. Abdul-Haqq in a worse condition; (2) there is no evidence that Dr. Miodovnik took over the duties the nurse-midwives owed to Mrs. Abdul-Haqq; and (3) there is no evidence that the injury in question was suffered because the chart review took place. Restatement (Second) of Torts § 324, which provides, "One who, being under no duty to do so, takes charge of another who is helpless adequately to aid or protect himself is subject to liability to the other for any bodily harm caused to him by (a) the failure of the actor to exercise reasonable care to secure the safety of the other while within the actor's charge, or (b) the actor's discontinuing his aid or protection, if by so doing he leaves the other in a worse position than when the actor took charge of him," is also inapplicable because: (1) Mrs. Abdul-Haqq was not in a helpless state when Dr. Miodovnik and Nurse-Midwife Alexander conducted the chart review; (2) Dr. Miodovnik did not take charge of her care and treatment; and (3) Dr. Miodovnik did not, through his actions or inaction, leave Mrs. Abdul-Haqq in a worse condition.
. Appellants argue that a duty of care should be imposed upon Dr. Miodovnik because the harm to Ilyaas Gilbert was foreseeable to him. But, as the trial court correctly held, "Whether a duty exists is not simply a question of foreseeability. It is ultimately a question of fairness and involves a weighing of the relationship of the parties, the nature of the risk, and the public interest in the proposed solution." Knippen v. Ford Motor Co., 178 U.S.App. D.C. 227, 234, 546 F.2d 993, 1000 (1976) (internal quotation marks and alterations omitted). See Odemns v. District of Columbia, 930 A.2d 137, 144 (D.C.2007) (declining to impose a duty upon WASA under the foreseeability of harm test); Hoehn v. United States, 217 F.Supp.2d 39, 45 (D.D.C.2002) (quoting Knippen).
. Section 314 of the Restatement provides: "The fact that the actor realizes or should realize that action on his part is necessary for another's aid or protection does not of itself impose upon him a duty to take such action."
. Contrary to the suggestion of the dissent, see post at 1015, our holding in no way implies a general rule "that under District of Columbia law there is no duty for a consulting physician to render appropriate advice simply because the patient is primarily being treated by another primary care giver."