Title: Da Silva v. WakeMed
Citation: N/A
Docket Number: 326PA18
State: north-carolina
Issuer: north-carolina Supreme Court
Date: August 14, 2020

IN THE SUPREME COURT OF NORTH CAROLINA 
No. 326PA18   
Filed 14 August 2020 
RAYMOND A. DA SILVA, Executor of the Estate of DOLORES J. PIERCE 
 
 
 
v. 
WAKEMED, WAKEMED d/b/a WAKEMED CARY HOSPITAL, and WAKEMED 
FACULTY PRACTICE PLAN 
 
On discretionary review pursuant to N.C.G.S. § 7A-31 of a unanimous, 
unpublished decision of the Court of Appeals, 817 S.E.2d 628, 2018 WL 3978021 (N.C. 
Ct. App. 2018), reversing an order entered on 13 February 2017 and an order entered 
on 20 February 2017 and vacating an order entered on 13 February 2017 by Judge 
Robert H. Hobgood in Superior Court, Wake County. Heard in the Supreme Court on 
15 June 2020. 
Law Offices of Gregory M. Kash, by Gregory M. Kash, for plaintiff-appellee.  
 
Fox Rothschild LLP, by Matthew Nis Leerberg; and Smith, Anderson, Blount, 
Dorsett, Mitchell & Jernigan, L.L.P., by John D. Madden and Robert E. 
Desmond, for defendant-appellants. 
 
Stephen J. Gugenheim and Anna Kalarites for North Carolina Advocates for 
Justice, amicus curiae. 
 
 
HUDSON, Justice.  
 
 
Here, we must determine whether an internist proffered by plaintiff to provide 
standard of care expert testimony against three hospitalists is properly qualified 
under Rule 702(b) of the North Carolina Rules of Evidence. We conclude that 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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plaintiff’s expert is qualified and affirm the decision of the Court of Appeals. We also 
must decide whether there is sufficient evidence in the record to raise a genuine issue 
of material fact that the hospitalists proximately caused plaintiff’s injury. We 
conclude that the record evidence here was sufficient and thus also affirm the decision 
of the Court of Appeals as to this issue. 
I. 
Factual & Procedural History 
This case began when a 76-year-old woman, Dolores Pierce, was hospitalized 
at WakeMed Cary Hospital from 30 October 2012 to 5 November 2012. Mrs. Pierce 
had been taking a daily dose of prednisone—a corticosteroid used to treat an 
inflammatory disorder—for years before being hospitalized. At the WakeMed Cary 
emergency room, she presented with fever, altered mental status, and weakness; she 
was presumed to have a urinary tract infection. Concerned that an infection had 
induced sepsis, emergency room personnel collected urine and blood cultures and a 
physician ordered the antibiotic Levaquin to be administered intravenously.  
Levaquin is an antibiotic commonly used to treat infection. Levaquin has a 
“black box” warning,1 the strongest warning required by the Food and Drug 
Administration (FDA). The “black box” on Levaquin warns of an increased risk of 
tendon ruptures in patients over sixty years old and in patients who are 
                                                 
1 21 C.F.R. § 201.57(c)(1) (2015). 
 
 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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concomitantly taking a corticosteroid. The most prevalent tendon rupture 
attributable to Levaquin use is the rupture of the Achilles tendon.  
Within hours of arriving at the emergency room, Mrs. Pierce was admitted to 
a telemetry-intermediate care floor and came under the care of physicians at 
WakeMed Cary Hospital, three of whom are relevant here: Dr. Jenkins, Dr. Daud, 
and Dr. Afridi (the hospitalists). All three of these doctors are board certified in 
internal medicine, and they all identify themselves as hospitalists—physicians who 
specialize in internal medicine in a hospital setting and care for hospitalized patients.  
During Mrs. Pierce’s stay, each of these hospitalists prescribed her Levaquin 
and continued her on a daily dose of prednisone. All three doctors testified that they 
were familiar with Levaquin and its “black box” warning at the time they prescribed 
the medication. They also testified that they were aware Mrs. Pierce was over the age 
of sixty and was taking a corticosteroid.  
When Mrs. Pierce was ultimately discharged to a rehabilitation facility, Dr. 
Afridi’s discharge orders included orders to continue Mrs. Pierce on Levaquin and 
prednisone. Per those orders, both drugs were administered through 9 November 
2012 at the rehabilitation facility. Mrs. Pierce was discharged within the next few 
days. Roughly a week after her discharge, Mrs. Pierce’s Achilles tendon ruptured, and 
she had to undergo tendon repair surgery. She never fully recovered and ultimately 
died from pneumonia and debility on 7 September 2013. 
Raymond Da Silva, the executor of Mrs. Pierce’s estate, brought this medical 
malpractice action seeking recovery for the tendon rupture and Mrs. Pierce’s 
DA SILVA V. WAKEMED 
 
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resulting injury and death. The only claims remaining arise from the hospitalists’ 
alleged medical negligence. Mr. Da Silva is thus the plaintiff in this capacity.  
During discovery, plaintiff identified experts and provided the deposition of Dr. 
Paul Genecin as expert testimony on the standard of care in compliance with Rule 
26(b)(4) of the North Carolina Rules of Civil Procedure. Defendant moved to 
disqualify Dr. Genecin and moved for summary judgment on the issue of proximate 
cause.  The trial court concluded that Dr. Genecin did not qualify as an expert. 
Because Dr. Genecin was plaintiff’s only “standard of care” expert, the trial court 
granted summary judgment for defendant based on plaintiff’s failure to provide any 
evidence proving a violation of the standard of care. The trial court also granted 
summary judgment for defendant on the issue of proximate cause.  
Plaintiff appealed. The Court of Appeals unanimously concluded that Dr. 
Genecin was competent to testify as to the standard of care and that his testimony 
sufficiently forecasted proximate cause. Da Silva v. WakeMed, 817 S.E.2d 628, 2018 
WL 3978021, at *9, *11 (N.C. Ct. App. 2018). As a result, the Court of Appeals 
reversed the trial court’s order disqualifying Dr. Genecin as an expert witness, 
vacated the trial court’s order granting summary judgment due to lack of expert 
testimony, and reversed the trial court’s order granting summary judgment due to 
lack of evidence of proximate cause. Id. at *11. Defendant filed a petition for 
discretionary review, which we allowed. We now affirm the decision of the Court of 
Appeals. 
 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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II. 
Rule 702(b) 
A. Standard of Review 
Generally, the trial court’s decision to allow or disqualify an expert “will not be 
reversed on appeal absent a showing of abuse of discretion.” State v. McGrady, 368 
N.C. 880, 893, 787 S.E.2d 1, 11 (2016) (quoting Howerton v. Arai Helmet, Ltd., 358 
N.C. 440, 458, 597 S.E.2d 674, 686 (2004)). “The standard of review remains the same 
whether the trial court has admitted or excluded the testimony—even when the 
exclusion of expert testimony results in summary judgment and thereby becomes 
‘outcome determinative.’ ” Id. at 893, 787 S.E.2d at 11 (quoting Gen. Elec. Co. v. 
Joiner, 522 U.S. 136, 142–43 (1997)). 
However, when the pertinent inquiry on appeal is based on a question of law—
such as whether the trial court properly interpreted and applied the language of a 
statute—we conduct de novo review. 2 Here, plaintiff argues that the trial court erred 
as a matter of law by misinterpreting and misapplying Rule 702 and disqualifying 
Dr. Genecin as an expert. Consequently, we review this issue de novo. Morris 
Commc'ns Corp. v. City of Bessemer City Zoning Bd. of Adjustment, 365 N.C. 152, 
155, 712 S.E.2d 868, 871 (2011) (“Reviewing courts apply de novo review to alleged 
errors of law[.]”). 
 
                                                 
2 Additionally, an error of law is an abuse of discretion. See Koon v. United States, 518 
U.S. 81, 100 (1996) (“A [trial] court by definition abuses its discretion when it makes an error 
of law.”); see also Matter of A.U.D., 373 N.C. 3, 13, 832 S.E.2d 698, 704 (2019) (Newby, J., 
dissenting) (“A trial court’s misapplication of the law is an abuse of discretion.”). 
DA SILVA V. WAKEMED 
 
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B. Rule 702(b)  
Rule 702(b) of the North Carolina Rules of Evidence provides: 
(b) In a medical malpractice action as defined in G.S. 90-
21.11, a person shall not give expert testimony on the 
appropriate standard of health care as defined in G.S. 90-
21.12 unless the person is a licensed health care provider 
in this State or another state and meets the following 
criteria: 
 
(1) 
 If the party against whom or on whose behalf 
the testimony is offered is a specialist, the expert 
witness must: 
 
a.  
Specialize in the same specialty as the 
party against whom or on whose behalf the 
testimony is offered; or 
 
b.  
Specialize in a similar specialty which 
includes within its specialty the performance 
of the procedure that is the subject of the 
complaint and have prior experience treating 
similar patients. 
 
(2)  
During the year immediately preceding the 
date of the occurrence that is the basis for the action, 
the expert witness must have devoted a majority of 
his or her professional time to either or both of the 
following: 
 
a.  
The active clinical practice of the same 
health profession in which the party against 
whom or on whose behalf the testimony is 
offered, and if that party is a specialist, the 
active clinical practice of the same specialty or 
a similar specialty which includes within its 
specialty the performance of the procedure 
that is the subject of the complaint and have 
prior experience treating similar patients; or 
 
b.  
The instruction of students in an 
accredited health professional school or 
DA SILVA V. WAKEMED 
 
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accredited residency or clinical research 
program in the same health profession in 
which the party against whom or on whose 
behalf the testimony is offered, and if that 
party is a specialist, an accredited health 
professional school or accredited residency or 
clinical research program in the same 
specialty. 
 
N.C. R. Evid. 702(b) (2019). From the language of this rule, we discern the following 
three requirements that Dr. Genecin must fulfill in order to provide expert testimony 
against the hospitalists, who hold themselves out as specialists3:  
(1) Dr. Genecin must be a licensed health care provider in North Carolina or 
another state;  
(2) Dr. Genecin must have the same specialty as the hospitalists or have a 
similar specialty; if Dr. Genecin has a similar specialty, his specialty must include 
the performance of the procedure that is the subject of the complaint and he must 
have prior experience treating patients similar to plaintiff; and  
(3) Dr. Genecin must have devoted the majority of his professional time to 
either the active clinical practice of the same or similar specialty as the hospitalists 
and/or the instruction of students in the same specialty during the year immediately 
preceding plaintiff’s hospitalization. 
We examine the record for evidence of each of these three requirements. 
                                                 
3 See FormyDuval v. Bunn, 138 N.C. App. 381, 388, 530 S.E.2d 96, 101 (2000) (“We 
thus hold that a doctor who is either board certified in a specialty or who holds himself out 
to be a specialist or limits his practice to a specific field of medicine is properly deemed a 
“specialist” for purposes of Rule 702.”). 
DA SILVA V. WAKEMED 
 
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C. Dr. Genecin’s Qualifications 
First, we note that Dr. Genecin testified in his video deposition that he is a 
licensed health care provider in Connecticut. Defendant lodged no objection to this 
testimony. 
Second, we must determine whether Dr. Genecin has the same or similar 
specialty as the hospitalists. The record shows that Dr. Genecin is board certified in 
internal medicine, meaning that he specializes in and is known as an internist. As 
noted above, defendant’s physicians hold themselves out as hospitalists, meaning 
that they specialize in internal medicine in a hospital setting and care for hospitalized 
patients. Like, Dr. Genecin, the hospitalists are all board certified in internal 
medicine. The hospitalists and Dr. Genecin also have similar education, training, and 
experience. Though Dr. Genecin’s practice is broader in scope, it includes the scope of 
the hospitalists’ practice. Dr. Genecin testified that “[a] hospitalist is a job title that 
an internal medicine doctor can assume by going to work full time for a hospital. The 
work that a hospitalist does is the same work as any internist who cares for 
hospitalized patients.” The record reveals no evidence to the contrary. Based on the 
evidence here that Dr. Genecin and the hospitalists all practice within the same scope 
of internal medicine, we conclude that the evidence shows that here, internist and 
hospitalist are similar specialties.4  
                                                 
4 We express no opinion here as to whether internist and hospitalist are the same 
specialty. 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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Next, we examine the record to see whether Dr. Genecin’s work as an internist 
includes the performance of the procedure that was the subject of the complaint. The 
complaint provides a description of the procedures at issue here and alleges the 
following ways in which the hospitalists deviated from the standard of care: (1) they 
administered Levaquin even when contraindicated by boxed warnings and when 
other antibiotics were available; (2) they administered a corticosteroid while plaintiff 
was also taking Levaquin; (3) they failed to properly identify and assess whether 
plaintiff was a proper candidate for the medications administered; (4) they failed to 
ensure proper medication reconciliation; (5) they ordered incorrect medications in 
excessive dosages; and (6) they discharged and transferred plaintiff with orders to 
continue Levaquin. These allegations all pertain to the selection and prescription of 
medication and a physician’s responsibility to recognize potential drug interactions.  
In the complaint, plaintiff also alleged other deviations from the standard of 
care by the hospitalists: (1) they failed to assess, obtain, and document accurate 
information in the medical records regarding plaintiff’s medical record and 
medication history, (2) they discharged plaintiff without appropriately reviewing her 
medical chart, and (3) they failed to communicate with one another. These allegations 
all involve the overall care and management of a patient.   
Thus, for purposes of our decision, the procedure that is the subject of the 
complaint includes the selection, prescription, and management of medication in the 
overall care of a patient. This includes, or course, a physician’s responsibility to 
recognize drug warnings and interactions.  
DA SILVA V. WAKEMED 
 
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Defendant argues that this characterization of the procedure is too broad 
because “just about every physician prescribes medications and makes referrals.” 
However, if the physician is a specialist, Rule 702(b) also requires that the procedure 
be part of a similar specialty. Thus, not every physician who selects, prescribes, and 
reconciles medications in the overall care and management of a patient would be 
qualified to testify here. Pursuant to Rule 702(b), the physician must do these things 
within the context of a similar specialty and have experience treating patients similar 
to the plaintiff. 
It is clear from Dr. Genecin’s testimony that his practice as an internist 
includes the procedures alleged here. He testified that he has experience reading and 
understanding the labeling of drugs, selecting and prescribing drugs, and recognizing 
potential reactions between drugs. He has also prescribed Levaquin to patients in the 
past. When working at the Yale Health Center, he does “all of the direct patient-care 
activities involved in internal medicine practice.” This includes making referrals, 
reading results, and writing prescriptions. Dr. Genecin also works as an attending 
physician in a hospital two months out of the year, where his primary duty is patient 
care. This includes admitting patients, assessing patient history and clinical findings, 
reading test results, assessing patient problems, recommending treatment 
appropriate to patient needs, and planning for the discharge and appropriate 
transition of patients. Dr. Genecin also testified that as an internist in the hospital 
his “role is identical [to that of the hospitalists] with respect to the care provided to 
the patients.” Again, the record contains no evidence to the contrary. We conclude 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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that this testimony is sufficient to satisfy the requirement that Dr. Genecin’s practice 
as an internist includes the procedures alleged in the complaint. 
Next, we review the record to determine whether Dr. Genecin has prior 
experience treating patients similar to Mrs. Pierce. When asked about this in his 
deposition, he responded with the following: 
I see patients of Mrs. Pierce’s demographic, elderly female 
patients in their 70s, many dozen per year in the hospital 
setting, admitted through the hospital with serious 
infections of one sort or another including, frequently, with 
infection arising in the urinary tract including the kidney. 
. . . 
 
Later in the same deposition, he explained Mrs. Pierce’s condition: “[S]he was an 
elderly patient with sepsis, urosepsis, needing I.V. antibiotics and inpatient care.” 
Dr. Genecin was then asked if he had seen patients like her in the emergency room 
when he was acting as an attending physician and he responded, “yes, all the time.” 
This evidence showed without equivocation that Dr. Genecin had prior experience 
with patients similar to Mrs. Pierce. 
Third and finally, in order to qualify to testify against the hospitalists, Dr. 
Genecin must have spent the majority of his professional time the year prior to Mrs. 
Pierce’s hospitalization in active clinical practice as an internist or hospitalist or 
instructing students in the hospitalist specialty. Clinical practice is the active 
practice of seeing patients in a clinical setting. See FormyDuval v. Bunn, 138 N.C. 
App. 381, 391, 530 S.E.2d 96, 103 (2000) (“Clinical is defined as ‘based on or 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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pertaining to actual experience in the observation and treatment of patients.’ ” 
(citation omitted)).  
Dr. Genecin testified without objection that in the year prior to Mrs. Pierce’s 
hospitalization he spent 55%–60% of his overall professional time in clinical practice 
as an internist, including two months of the year in which he practiced internal 
medicine in a hospital full time. As explained above, there is evidence in the record 
that Dr. Genecin’s clinical practice included the performance of the procedure that is 
the subject of the complaint and that he had experience treating patients similar to 
plaintiff. Thus, we conclude that the evidence shows without contradiction that Dr. 
Genecin spent the majority of his professional time the year prior to Mrs. Pierce’s 
hospitalization in the active clinical practice of a qualifying specialty similar to the 
hospitalists. 
The record contains undisputed evidence that Dr. Genecin meets each of the 
applicable requirements of Rule 702(b). Therefore, we conclude that Dr. Genecin may 
properly offer expert testimony on the standard of care against the hospitalists. We 
conclude that the trial court erred as a matter of law and affirm the decision of the 
Court of Appeals on this issue. 
III. 
Proximate Cause 
We review de novo a trial court’s order granting summary judgment. Sykes v. 
Health Network Solutions, Inc., 372 N.C. 326, 332, 828 S.E.2d 467, 471 (2019). 
Summary judgment is appropriate “if the pleadings, depositions, answers to 
interrogatories, and admissions on file, together with the affidavits, if any, show that 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
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there is no genuine issue as to any material fact and that any party is entitled to a 
judgment as a matter of law.” N.C.G.S. § 1A-1, Rule 56(c) (2019). We review the 
evidence in the light most favorable to the non-moving party. McCutchen v. 
McCutchen, 360 N.C. 280, 286, 624 S.E.2d 620, 625 (2006). 
“Proximate cause is ordinarily a jury question.” Turner v. Duke Univ., 325 N.C. 
152, 162, 381 S.E.2d 706, 712 (1989) (citing Conley v. Pearce-Young-Angel Co., 224 
N.C. 211, 29 S.E.2d 740 (1944)). In a case like this one where the allegations in the 
complaint and the evidence in the record indicate that there may be multiple 
proximate causes of the plaintiff’s injury, a genuine issue of material fact remains, 
and summary judgment is not proper. See King v. Allred, 309 N.C. 113, 118, 305 
S.E.2d 554, 558 (1983) (holding that where the facts did not preclude a finding by the 
jury that defendant’s negligence “was a proximate cause or the proximate cause” of 
the injury, the court could not conclude as a matter of law that the negligence of the 
defendant was the sole proximate cause of plaintiff’s injury and summary judgment 
was not proper). 
 
During his deposition, Dr. Genecin stated repeatedly that the prescription of 
Levaquin caused plaintiff’s injury. He testified that: 
Levaquin was the cause of the tendon rupture that Mrs. 
Pierce had within the classic time frame, less than 30 days 
of therapy; in the classic location, the Achilles tendon; 
under the circumstances that are described in the black box 
warning, an elderly woman treated with Levaquin while on 
prednisone. 
 
He went on to reiterate: 
DA SILVA V. WAKEMED 
 
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Q:  
. . . In addition to your opinions on standard of care, 
. . . do you have an opinion, Doctor, to a reasonable degree 
of medical certainty . . . as to whether or not Ms. Pierce 
suffered any injury that was proximately caused by being 
prescribed Levaquin when she’s over the age of 60 and 
concomitantly taking a corticosteroid? 
 
. . . 
 
A: 
I do have an opinion. 
 
Q: 
And that is? 
 
. . . 
 
A: 
That she suffered a tendon rupture as a consequence 
of unsafe use of Levaquin because of her age and 
corticosteroid use. 
 
In the light most favorable to the plaintiff, a jury could reasonably find that “unsafe 
use of Levaquin” refers to the unsafe prescription of Levaquin by any of the doctors 
treating Mrs. Pierce, including the hospitalists. 
 
Defendant asks us to find that the following exchange during cross-
examination negates these affirmative statements of causation: 
Q:  
. . . Would you agree with me that all you can say, 
with respect to any connection between the Levaquin and 
the resulting injury to Ms. Pierce, is that if the Levaquin 
had been stopped by [any of the hospitalists] that all that 
would have done would have been to reduce the risk or, say 
it another way, improve her chances of avoiding an Achilles 
tendon rupture? 
 
A:  
That’s true. . . . the shorter the duration, the less the 
risk. . . . It’s best not to start it if you can avoid it in a 
situation like this. But the shorter course is safer than the 
long course. 
 
DA SILVA V. WAKEMED 
 
Opinion of the Court 
 
-15- 
This exchange during cross examination does not negate Dr. Genecin’s consistently 
expressed opinion that Levaquin caused the injury. Though the evidence shows that 
Mrs. Pierce had already been prescribed Levaquin by the emergency room physician 
when she was formally admitted into the care of the hospitalists, plaintiff is not 
required to prove that the hospitalists’ prescription of Levaquin was the sole or 
exclusive cause of her injury, only that it was a proximate cause. See Turner, 325 N.C. 
at 162, 381 S.E.2d at 712 (“When a defendant moves for a directed verdict in 
a medical malpractice case, the question raised is whether the plaintiff has offered 
evidence of each of the following elements of his claim for relief: (1) the standard of 
care, (2) breach of the standard of care, (3) proximate causation, and (4) damages.” 
(emphasis added)).  
Here, Dr. Genecin’s testimony during direct examination is not negated by, 
and is not even necessarily inconsistent with, the quoted excerpt from the cross-
examination. Taken in the light most favorable to plaintiff, a jury could find that the 
prescription of Levaquin was a cause of Mrs. Pierce’s injuries and that the 
hospitalists’ continued prescription of Levaquin was or was not a contributing cause. 
That is for the jury to decide.5  
                                                 
5 We note that, to the extent that the parties argued it, we do not rely on Gower v. 
Davidian, 212 N.C. 172, 193 S.E. 28 (1937), or the loss of chance doctrine in support of our 
holding. 
DA SILVA V. WAKEMED 
 
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We conclude that plaintiff presented sufficient evidence of proximate cause 
such that summary judgment is inappropriate. We affirm the decision of the Court of 
Appeals as to this issue. 
IV. 
Conclusion 
We conclude that Dr. Genecin was qualified to testify to the standard of care 
and that his testimony sufficiently forecasted proximate cause. As a result, we affirm 
the decision of the Court of Appeals to reverse the trial court’s order disqualifying Dr. 
Genecin as an expert witness, and we affirm the decision of the Court of Appeals to 
vacate the trial court’s order allowing summary judgment due to lack of expert 
testimony. We also affirm the decision of the Court of Appeals to reverse the trial 
court’s order granting summary judgment due to lack of evidence of proximate cause. 
 
AFFIRMED. 
 
 
 
 
 
 
 
Justice DAVIS concurring in part and dissenting in part. 
I concur with the portion of the majority’s opinion holding that Dr. Genecin 
was qualified to testify as an expert witness and offer an opinion at trial. However, 
for the reasons stated in Justice Newby’s dissent, I respectfully dissent from the 
portion of the majority’s opinion holding that plaintiff presented sufficient evidence 
on the issue of proximate cause through Dr. Genecin’s testimony to overcome 
defendants’ motion for summary judgment. Accordingly, I would hold that the Court 
of Appeals erred in reversing the trial court’s entry of summary judgment in favor of 
defendants. 
 
 
 
 
 
 
 
 
 
 
Justice NEWBY dissenting. 
To succeed in this medical malpractice case, plaintiff must show that 
defendants violated the applicable standard of care by continuing the administration 
of Levaquin in a hospital setting to a patient who is suffering from a life-threatening 
infection. Further, plaintiff must demonstrate that a violation of the standard of care 
proximately caused Pierce’s injury. Plaintiff has only one expert witness to establish 
the standard of care, breach of that standard by defendants, and whether the breach 
proximately caused the injury: Doctor Genecin. Dr. Genecin testified via a trial 
deposition. In properly applying the statutory and case law, the trial court 
determined Dr. Genecin did not meet the statutory requirements to render an expert 
opinion critical of defendants. In addition, after carefully evaluating Dr. Genecin’s 
testimony, the only evidence of proximate causation, the trial court found the 
evidence inadequate to establish proximate causation. The trial court was correct. Dr. 
Genecin, an internal medicine physician, does not qualify to testify about the 
standard of care of hospitalists. Similarly, Dr. Genecin’s testimony does not establish 
that the actions of the hospitalists caused plaintiff’s injuries. 
In its decision reversing the trial court, the majority undermines the General 
Assembly’s carefully crafted statutory scheme designed to ensure that only colorable 
medical malpractice claims are presented to juries. The majority asks the wrong 
questions and therefore gets the wrong answers. First, considering whether Dr. 
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
-2- 
 
Genecin is qualified to testify against defendants, the majority asks the broad 
question of whether the general medical work involved in this case is the sort of work 
that Dr. Genecin often performs. It instead should have asked whether Dr. Genecin’s 
specialty often requires him to perform the actual care at issue; whether he frequently 
must decide whether to continue a patient with a life-threatening condition on a 
medication that had been prescribed by someone else and that appears to be helping 
the patient recover. To reach its result, the majority undermines the longstanding 
deferential standard of review, which recognizes the factual nature of the inquiry into 
an expert witness’s qualifications. It now designates this inquiry to be a legal issue. 
Second, the majority asks whether Dr. Genecin testified that the relevant medication, 
Levaquin, proximately caused the tendon rupture. It instead should have asked 
whether Dr. Genecin testified that the procedure at issue, the hospitalists’ continued 
administration of Levaquin that had already been prescribed, proximately caused the 
rupture. Regardless, Dr. Genecin’s testimony was only that Levaquin increased the 
risk of the injury. Because the trial court correctly answered the right questions, I 
respectfully dissent.  
Seventy-six-year-old Dolores Pierce arrived at WakeMed Cary Hospital on 30 
October 2012, with severe confusion, a fever, and weakness. Upon initial 
examination, the emergency room physician1 thought that Pierce had a serious 
infection that was inducing sepsis, and prescribed her Levaquin, a common antibiotic, 
                                                 
1 The emergency room physician who originally prescribed Levaquin is not a 
defendant in this case. 
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
-3- 
 
to be administered intravenously. Levaquin is associated with an increased risk of 
tendon injury, but, for those with risk factors similar to those of Pierce, the antibiotic 
only presents about a three percent chance of such an injury.2 The emergency room 
physician admitted Pierce to the hospital, and she was transferred to the hospitalists’ 
care. The hospitalists diagnosed her with sepsis and identified her as “critically ill.” 
But they noticed that the Levaquin appeared to be helping fight her infection. They 
continued the Levaquin prescription to treat Pierce’s infection. Pierce remained in 
the hospital until 5 November 2012 when she had substantially recovered from her 
infection and was ready to be discharged. At that time, she was transferred to a 
rehabilitation facility and was instructed to continue Levaquin, along with her daily 
Prednisone, for four more days. On 19 November 2012, ten days after Pierce stopped 
taking Levaquin, she experienced a left Achilles tendon rupture. 
Plaintiff sued the hospital and the hospitalists for negligence. Plaintiff 
identified Dr. Genecin as an expert witness. Dr. Genecin specializes in internal 
medicine, but, by his own admission, is not a hospitalist. For only two months of the 
year, less than seventeen percent of his professional time, Dr. Genecin treats 
hospitalized patients as an attending physician. Most of his professional time he 
oversees outpatient care at a clinic. Dr. Genecin testified that working in such an 
                                                 
2 Dr. Genecin testified that around three out of every one thousand Levaquin takers 
suffers a tendon rupture, and that for those with certain risk factors like Pierce, the risk of 
such an injury is between three and ten times greater than that of the general population of 
Levaquin takers. Thus, even interpreting these numbers to indicate the greatest risk, 
Levaquin only poses about a thirty in one thousand, or three percent, risk of tendon rupture 
for those with risk factors like Pierce’s. 
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
-4- 
 
office practice is different than caring for patients in a hospital setting as an 
attending physician. Nevertheless, plaintiff sought to introduce Dr. Genecin’s 
testimony that in his professional opinion the hospitalists’ continued administration 
of Levaquin to Pierce represented conduct that fell below the applicable standard of 
medical care. 
Dr. Genecin also offered plaintiff’s only evidence on the issue of whether the 
hospitalists’ administering of Levaquin proximately caused Pierce’s tendon rupture. 
He testified that many different factors can increase the risk of a tendon rupture, 
including a patient’s age, a patient’s taking of corticosteroids, a patient’s history of 
having a kidney transplant, and a patient’s taking of Levaquin. Focusing on the 
Levaquin risk factor, Dr. Genecin’s testimony indicated that, for someone who 
possesses all the risk factors Pierce had, the chance of suffering a tendon injury from 
the Levaquin is only around three percent. Dr. Genecin nevertheless named Levaquin 
as the cause of Pierce’s injury. But, on cross examination, he admitted that other 
factors likely contributed to the rupture, and that all he could say was that her 
chances of avoiding injury would have been better had the hospitalists not continued 
her Levaquin treatment as they did. He also admitted that he himself prescribed 
Levaquin to his patients and agreed that “the Levaquin effectively treated [Pierce’s] 
infection and she survived that potentially life-threatening disease.” Dr. Genecin’s 
deposition testimony was the only evidence presented by plaintiff on the issues of 
defendants’ standard of care and whether defendants’ conduct proximately caused 
Pierce’s tendon rupture. 
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Newby, J., dissenting 
 
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Defendants moved to disqualify Dr. Genecin as an expert witness, and moved 
for summary judgment. The trial court reviewed the record evidence and granted both 
motions. The Court of Appeals reversed. 
An appellate court should reverse a decision of the trial court that a witness 
does not qualify to testify as an expert under Rule 702 only if the trial court abused 
its discretion. State v. McGrady, 368 N.C. 880, 893, 787 S.E.2d 1, 11 (2016). A trial 
court abuses its discretion if “its ruling was manifestly unsupported by reason and 
could not have been the result of a reasoned decision.” State v. Riddick, 315 N.C. 749, 
756, 340 S.E.2d 55, 59 (1986). In recognition of the fact-intensive nature of the 
inquiry, trial courts are granted “wide latitude” in determining if an expert is 
qualified to testify under Rule 702. Moore v. Proper, 366 N.C. 25, 30, 726 S.E.2d 812, 
817 (2012) (quoting State v. Bullard, 312 N.C. 129, 140, 322 S.E.2d 370, 376 (1984)). 
As this Court said in McGrady, “[t]he standard of review [of a trial court’s decision 
under Rule 702] remains the same . . . even when the exclusion of expert testimony 
results in summary judgment and thereby becomes ‘outcome determinative.’ ” 368 
N.C. at 893, 787 S.E.2d at 11 (quoting Gen. Elec. Co. v. Joiner, 522 U.S. 136, 142–43, 
118 S. Ct. 512, 517 (1997)). However, a trial court’s decision to grant summary 
judgment is reviewed de novo. Sykes v. Health Network Sols., Inc. 372 N.C. 326, 332, 
828 S.E.2d 467, 471. (2019). 
Here, while citing the correct deferential standard of review of the trial court’s 
determination of the expert’s qualifications, the majority conducts a de novo review, 
stating that questions about the meaning of statutes like Rule 702 are questions of 
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Newby, J., dissenting 
 
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law to be reviewed de novo. Certainly a bona fide question of statutory interpretation 
should be reviewed de novo, but such a question is not at issue in this case. The 
question here simply concerns the rule’s application to the facts, in other words, 
whether plaintiff’s purported expert witness in fact has the requisite specialized 
training and experience qualifying him to testify against the hospitalists under Rule 
702. How the nature of a witness’s work and the length of time the witness spends 
performing that work is a question of law instead of fact, the majority does not say. 
As evidenced by its analysis, the majority simply reweighs the evidence to reach its 
result. It ignores the differing nature of the work of hospitalists and clinicians and 
decides, contrary to the trial court’s decision, that Dr. Genecin’s work is similar 
enough to the defendants’ work to qualify him to testify. This approach contradicts 
our case law. In McGrady, we plainly said that a trial court’s decision that a witness 
does not qualify to testify as an expert under Rule 702 is reviewed for an abuse of 
discretion. 368 N.C. at 893, 787 S.E.2d at 11. 
Through Rule 702(b), the General Assembly has established strict criteria that 
must be met for someone to qualify as an expert witness competent to testify against 
a medical professional. Under the rule’s first requirement, the proffered witness must 
either specialize in the same specialty as the party against whom the testimony is 
offered, or be of a similar specialty that includes the medical care at issue and have 
experience treating the same sort of patients. N.C.G.S. § 8C-1, Rule 702(b)(1) (2019). 
Under the rule’s second requirement, the witness, in the year leading up to the 
occurrence that is the basis for the action, must  
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
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have devoted a majority of his or her professional time to 
either . . . [t]he active clinical practice of the same health 
profession in which the party against whom or on whose 
behalf the testimony is offered, and if that party is a 
specialist, the active clinical practice of the same specialty 
or a similar specialty which includes within its specialty the 
performance of the procedure that is the subject of the 
complaint and have prior experience treating similar 
patients; or [t]he instruction of students in an accredited 
health professional school or accredited residency or 
clinical research program in the same health profession in 
which the party against whom or on whose behalf the 
testimony is offered, and if that party is a specialist, an 
accredited health professional school or accredited 
residency or clinical research program in the same 
specialty.  
N.C.G.S. § 8C-1, Rule 702(b)(2) (emphasis added). The trial court reasonably found 
that Dr. Genecin does not satisfy these requirements. 
Neither the trial court, nor the Court of Appeals, nor the majority of this Court 
assert that Dr. Genecin is of the same specialty as the hospitalists.3 The majority 
instead holds that Dr. Genecin’s practice is of a similar specialty to that of the 
hospitalists. Though all these doctors are trained in and practice internal medicine, 
the nature of a hospital practice and that of an outpatient clinic are vastly different. 
Yet, as the majority notes, it is not enough for the witness to work in a similar 
specialty. His specialty must also include the procedure at issue in the lawsuit, and 
he must have spent the majority of his professional time working in that similar 
                                                 
3 Though the majority does not do so, I would hold that Dr. Genecin and the 
hospitalists are not of the same specialty because of the hospitalists’ unique form of care, 
which is administered in a hospital under more emergency circumstances than in a clinic. 
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specialty that includes the procedure at issue (or teaching in such a specialty). 
N.C.G.S. § 8C-1, Rule 702(b)(1)–(2). 
Dr. Genecin’s specialty as an internist at an outpatient clinic does not include 
the procedure at issue here. The majority states that the medical care at issue in this 
case is “the selection, prescription, and management of medication in the overall care 
of a patient.” But that characterization is too broad.4 The majority asks a general 
question about whether both Dr. Genecin and the hospitalists prescribe medications, 
when it should ask a more specific question tailored to the medical care actually at 
issue in this case. The procedure at issue is the hospitalists’ overseeing of the 
continued administration of Levaquin to Pierce after an emergency room physician 
had already started her on the medication and after it appeared to be helping her 
recover from a potentially life-threatening infection. Defendants thus were called to 
provide patient care for Pierce in the midst of an ongoing medical emergency. 
Dr. Genecin’s clinical work does not, however, involve such emergency 
decisions and the precise cost-benefit analyses which they entail. Indeed, Dr. Genecin 
agreed that the administering of Levaquin appears to have helped Ms. Pierce recover 
from a potentially life-threatening infection. Patients at Dr. Genecin’s clinic who 
appear to be in serious condition are referred from the clinic to the hospital for the 
hospital to administer emergency care. Dr. Genecin may be an expert in internal 
                                                 
4 Moreover, the majority’s statement that the relevant care includes “selection” of 
medication is misleading. The hospitalists had no role in the original selection of Levaquin 
(or Prednisone). Instead, their role was to continue Pierce on Levaquin that was already being 
administered at the direction of a doctor who is not a party to this case. 
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
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medicine, and his clinical practice may call on him to understand how medications 
like Levaquin affect people with various risk factors. But his clinical practice does not 
call on him to exercise medical judgment about whether a person who is suffering 
from a life-threatening infection should continue taking a medication that has 
already been administered and which appears to be fighting the infection effectively, 
but may marginally inflate other risks. In his day-to-day work Dr. Genecin does not 
make such judgment calls, which require specialized medical training and expertise. 
Because the practice in which he spends the majority of his professional time does 
not include the medical care at issue in this case, the trial court properly disqualified 
him as an expert witness and did not allow him to testify regarding the hospitalists’ 
medical care. 
Dr. Genecin does have limited experience treating similar patients in a 
hospital setting, as he spends some time working at Yale New Haven Hospital as a 
hospital attending physician. But he does not spend the majority of his professional 
time in such a setting as required by the statute. Instead, by his own testimony, he 
spends only about two months out of the year at the hospital, roughly seventeen 
percent of his professional time. 
The trial court did not abuse its discretion when it disqualified Dr. Genecin 
from testifying as an expert witness regarding whether the hospitalists’ continued 
administration of Levaquin fell below the applicable standard of medical care. The 
DA SILVA V. WAKEMED 
 
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majority’s decision to the contrary inserts this Court into what is ultimately a 
factfinding role assigned to the trial court.5 
The trial court’s grant of summary judgment to defendants should be affirmed 
as well on the ground that plaintiff did not put forth sufficient evidence that 
defendants’ actions were the proximate cause of Pierce’s injury. In a medical 
malpractice case, “the plaintiff must establish proof of a causal connection between 
the negligence of the physician and the injury complained of by the testimony of 
medical experts.” McGill v. French, 333 N.C. 209, 217, 424 S.E.2d 108, 113 (1993). 
Thus, to survive summary judgment, plaintiffs had to present evidence that it was 
probable, in other words, more likely than not, that defendants’ purported negligence 
caused the injury. This Court has long held that it is not sufficient for a plaintiff to 
simply show that a different course of treatment by the defendant physician would 
have increased the plaintiff’s chances of avoiding the injury. See Gower v. Davidian, 
212 N.C. 172, 175–76, 193 S.E. 28, 30–31 (1937). So, unless the evidence, viewed in 
plaintiff’s favor, shows that the hospitalists’ conduct of continuing Pierce on Levaquin 
at the dosage and length of time they did probably caused her tendon rupture, the 
trial court’s grant of summary judgment in defendants’ favor should be affirmed.  
                                                 
5 The majority also notes that defendants raised “no objection to [Dr. Genecin’s] 
testimony” in his video deposition. If the majority means to say Dr. Genecin’s qualifications 
to testify as an expert are uncontested, it is obviously incorrect. From the beginning 
defendants have contested Dr. Genecin’s qualifications to testify as an expert against them, 
and the trial court decided in defendants’ favor on that point. 
DA SILVA V. WAKEMED 
 
Newby, J., dissenting 
 
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The majority again frames the question too broadly. Instead of asking whether 
Dr. Genecin testified that the actual medical care of the hospitalists proximately 
caused the tendon rupture, the majority is content to fixate on his testimony that 
Levaquin in general was the cause, even though Dr. Genecin vacillated on even that 
statement. 
Dr. Genecin never offered any testimony to the specific and central point that 
defendants’ failure to discontinue Levaquin caused Pierce’s Achilles tendon rupture. 
Rather, he testified that “Levaquin was the cause of the tendon rupture.” (emphasis 
added). The Levaquin was not, however, prescribed only by the hospitalists. An 
emergency department physician originally began intravenous administration of the 
medication, and the hospitalists continued Pierce on that medication after diagnosing 
her with a dangerous infection and noting that Levaquin appeared to be effectively 
treating her infection. It is the conduct of the hospitalists that is at issue. But the 
relevant testimony from Dr. Genecin on proximate cause does not target that conduct. 
Moreover, Dr. Genecin later clarified and qualified his statement regarding 
Levaquin as the cause of injury by agreeing that “all [he could] say” was that the 
hospitalists discontinuing the Levaquin would have “reduce[d] the risk or . . . 
improve[d] [Pierce’s] chances of avoiding an Achilles tendon rupture.” This assertion 
is not enough to show proximate causation. Again, this Court’s decision in Gower 
illustrates that a plaintiff cannot survive dismissal on the issue of causation simply 
by showing that another course of treatment would have reduced the risk of the 
injury. By qualifying his statements as he did, Dr. Genecin demonstrated that he was 
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Newby, J., dissenting 
 
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unable to say whether the administration of Levaquin was a substantial cause of the 
tendon rupture at all, not to mention whether the specific continuance decisions of 
the hospitalists proximately caused the injury. Instead, Dr. Genecin testified 
regarding a study that showed the risk of a tendon injury from taking Levaquin is 
only around three in one thousand, and that this risk is likely three to ten times 
higher for people with various risk factors. Thus, his testimony indicates at most 
around a thirty in one thousand, or three percent, risk of a tendon injury for those 
with risk factors like Pierce who take Levaquin. This Court has held that when an 
expert testifies merely to a possible cause of the injury, that testimony is insufficient 
to create a material issue of fact about whether the subject of the testimony 
proximately caused the plaintiff’s injury. See Gillikin v. Burbage, 263 N.C. 317, 324–
25, 139 S.E.2d 753, 759–60 (1965). By holding otherwise, the majority quietly applies 
the “loss of chance” doctrine, nonexistent under North Carolina law, which changes 
the traditional requirement of proximate cause and allows a plaintiff to prevail if she 
demonstrates that the medical care affected her chance of good health, no matter how 
small the effect may be. Under existing North Carolina law regarding proximate 
cause, Dr. Genecin’s testimony did not establish a material issue of fact regarding, or 
amount to sufficient evidence of, proximate cause, and the trial court’s grant of 
summary judgment was appropriate.  
Rule 702 helps ensure that reliable evidence is presented to support a 
plaintiff’s medical malpractice claim. A jury may be substantially swayed by anyone 
with the title of “doctor,” even if that doctor lacks the specialization and experience 
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Newby, J., dissenting 
 
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necessary to provide reliable testimony on the proper standard of professional 
medical care. Rule 702 thus limits expert testimony to those doctors who, through 
relevant training and experience, have significant information to contribute to the 
factfinder. Dr. Genecin undoubtedly possesses substantial knowledge and skill in 
internal medicine generally; but his practice does not require him to regularly make 
emergency decisions about a hospitalized patient’s care, which hospitalists must 
routinely make. The majority, by framing the question of Dr. Genecin’s specialization 
so broadly, misses this critical distinction. Moreover, the majority reweighs the 
evidence to reach its conclusion. The trial court did not abuse its discretion by 
disqualifying Dr. Genecin as an expert as to the hospitalists’ medical care at issue in 
this case. Further, because Dr. Genecin did not, and could not, testify that the 
hospitalists’ care caused Pierce’s tendon rupture, plaintiff did not present sufficient 
evidence of proximate causation, and the trial court appropriately granted summary 
judgment in defendants’ favor. The trial court’s decision was correct, and the decision 
of the Court of Appeals should be reversed.  
I respectfully dissent. 
Justice MORGAN joins in this dissenting opinion.