Title: Preston v. Movahed
Citation: N/A
Docket Number: 124PA19
State: north-carolina
Issuer: north-carolina Supreme Court
Date: April 3, 2020

IN THE SUPREME COURT OF NORTH CAROLINA 
No. 124PA19 
Filed 3 April 2020 
Donna J. PRESTON, Administrator of the Estate of WILLIAM M. PRESTON 
 
 
v. 
ASSADOLLAH MOVAHED, M.D., DEEPAK JOSHI, M.D., AND PITT COUNTY 
MEMORIAL HOSPITAL, INCORPORATED, D/B/A VIDANT MEDICAL CENTER 
 
On discretionary review pursuant to N.C.G.S. § 7A-31 of a unanimous decision 
of the Court of Appeals, 825 S.E.2d 657 (N.C. Ct. App. 2019), affirming an order 
entered on 25 October 2017 by Judge Jeffery B. Foster in Superior Court, Pitt County.  
Heard in the Supreme Court on 7 January 2020. 
Edwards Kirby, L.L.P., by John R. Edwards, David F. Kirby, and Mary 
Kathryn Kurth, and Laurie Armstrong Law, PLLC, by Laurie Armstrong, for 
plaintiff-appellant.   
 
Smith Anderson Blount Dorsett Mitchell & Jernigan, LLP, by John D. Madden 
and Robert E. Desmond, for defendant-appellee Assadollah Movahed, M.D. 
 
 
EARLS, Justice. 
 
 
Plaintiff, Donna Preston, the widow and estate representative of William M. 
Preston, appealed the trial court’s order granting the motion to dismiss of defendant, 
Dr. Assadolah Movahed,1 on the basis that plaintiff’s medical malpractice complaint 
                                            
1 Defendants Deepak Joshi, M.D., and Pitt County Memorial Hospital, Incorporated, 
d/b/a Vidant Medical Center were parties in the original appeal but settled with plaintiff 
prior to the issuing of the Court of Appeals’ opinion.  They were not parties to the appeal 
here.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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failed to comply with Rule 9(j) of the North Carolina Rules of Civil Procedure.  The 
Court of Appeals affirmed, holding that competent evidence supported the trial 
court’s determination that the expert witness retained by plaintiff to review Mr. 
Preston’s medical care was unwilling to testify that defendant did not comply with 
the applicable standard of care, notwithstanding that the evidence would support 
findings to the contrary.  Preston v. Movahed, 825 S.E.2d 657, 662–65 (N.C. Ct. App. 
2019).  Because we conclude that in the light most favorable to plaintiff the factual 
record demonstrates that at the time of the filing of the complaint plaintiff’s expert 
was willing to testify that defendant breached the applicable standard of care and 
plaintiff reasonably expected him to qualify as an expert, we reverse the decision of 
the Court of Appeals and remand for further proceedings.   
Background 
 
The undisputed facts from the pleadings and evidence before the trial court 
tend to show that on the morning of 3 February 2014, 54-year-old William Preston 
went to the emergency room at Vidant Medical Center complaining of shortness of 
breath and left-sided chest pain radiating to his left arm, symptoms that had begun 
twelve hours earlier.  The intake physician noted Mr. Preston’s risk factors for 
coronary artery disease, including hypertension, a history of smoking, and his age, 
and further noted that Mr. Preston’s chest pain was relieved by nitroglycerin.  
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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Electrocardiograms (EKGs2) taken in the emergency room were abnormal, suggesting 
myocardial ischemia, a condition where the heart receives insufficient blood flow.  
After about two hours, Mr. Preston again complained of left arm pain, which was 
again relieved by nitroglycerin.  Mr. Preston was admitted to the hospital for 
observation and the attending physician ordered further testing, including a “nuclear 
stress test.”   
In a nuclear stress test, an EKG is taken while the patient exercises on a 
treadmill.  The “nuclear” aspect involves injecting the patient with a “radiotracer” 
dye and using gamma rays to produce images of the patient’s heart.  During Mr. 
Preston’s test that took place on the following day, he reported severe “chest pain and 
left arm pain at a level of 10/10” and the test was terminated due to shortness of 
breath and fatigue.   
Defendant, a nuclear cardiologist, was assigned to read and interpret the 
results of Mr. Preston’s stress test.  In his deposition, defendant explained that when 
interpreting the results of a nuclear stress test, he receives a document with the 
patient’s information and medical history, EKG “tracings” from the exercise portion 
of the test, and the nuclear images.  Defendant stated that he reviews this 
information “stage by stage,” beginning with the patient’s history and risk factors, 
then reviewing the EKG tracings, and then finally the nuclear images.  According to 
                                            
2 The filings in the trial court and the parties’ briefs refer to electrocardiograms 
interchangeably as EKGs and ECGs.  We use only the term EKG for consistency.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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defendant, he “complete[s] one study, finish[es] with the study,” and moves to the 
next, making findings at each stage before making ultimate findings and preparing 
a report.   
Here defendant received Mr. Preston’s information sheet, which noted Mr. 
Preston’s use of tobacco, his hypertension, of which there was a family history, and 
his chest pain.  With respect to the EKG tracings, defendant’s written report noted 
that there was “no definite significant additional diagnostic ST segment depression 
or ST segment elevation recorded during exercise and recovery.”  Regarding the 
nuclear images, defendant’s report noted a perfusion defect in the heart, which he 
thought was likely due to “significant gas in the stomach” but could not rule out 
ischemia.  His report stated that “one may consider coronary CTA for further 
evaluation of coronary arteries in addition to aggressive risk factor modification.”3  
Defendant gave an oral report of his interpretation of the results of the test to his 
first-year cardiology fellow, Dr. Deepak Joshi, who entered a “fellow note” into Mr. 
Preston’s chart.  The note stated: “[n]uclear stress test showed mild ischemia versus 
attenuation artifact in the inferolateral/inferior apical area.  Discussed with Dr. 
Movahed, attending.  Recommend outpatient cardiac CTA.  Will arrange for the test 
and outpatient cardiology follow-up.  Plan discussed with primary team.”  
                                            
3 Defendant testified that aggressive risk factor modification refers to activities like 
ceasing smoking, losing weight, exercising, and using a low-dose aspirin.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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Dr. Neha Doctor, a hospitalist, examined Mr. Preston after the nuclear stress 
test.  Plaintiff alleges that she and Mr. Preston were informed that the cardiac tests 
had been negative and that Mr. Preston’s left-sided pain was likely neurological, not 
heart-related.  Dr. Doctor discharged Mr. Preston with instructions to follow up with 
his primary care physician about an MRI and to follow up with the CT angiogram 
(CTA) appointment made by the cardiology team.  This outpatient cardiology follow-
up was scheduled for sixteen days later on 20 February 2014.  
Two days after being discharged, Mr. Preston saw his primary care physician, 
who referred him for an MRI of his spine.  The MRI showed no neurological cause for 
Mr. Preston’s continuing left arm pain.   
On 13 February 2014, a week before his scheduled cardiac follow-up, Mr. 
Preston was at home when he called out to his wife.  When plaintiff reached her 
husband, she found him collapsed on the floor and unresponsive.  Responding to 
Plaintiff’s 911 call, EMS found Mr. Preston pulseless and breathing about four times 
per minute, and therefore began resuscitation measures and transporting him to 
Vidant Medical Center.  At Vidant’s Emergency Department, further resuscitation 
efforts were unsuccessful and Mr. Preston was pronounced dead at 5:35 that 
afternoon.  An autopsy revealed severe narrowing of the circumflex and right 
coronary arteries, acute and evolving myocardial infarction, and transmural rupture 
of the left ventricular wall of Mr. Preston’s heart.  
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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On 25 November 2015, plaintiff filed a wrongful death action (the First 
Complaint) naming multiple defendants involved in Mr. Preston’s medical care, 
including Dr. Neha Doctor.  In accordance with the special pleading requirements of 
section (j) (Medical malpractice) of Rule 9 (Pleading special matters) of the North 
Carolina Rules of Civil Procedure, plaintiff alleged in the complaint that the medical 
care and medical records pertaining to Mr. Preston’s treatment had been reviewed by 
a person reasonably expected to qualify as an expert witness under Rule 702 of the 
North Carolina Rules of Evidence and who was willing to testify that the medical care 
did not comply with the applicable standard of care.  Dr. Stuart Toporoff, a 
cardiologist, submitted an affidavit (his First Affidavit) averring that he had reviewed 
the medical care and records and was willing to testify that the care provided failed 
to comply with the applicable standard of care.  On 29 January 2016, Dr. Doctor filed 
an answer alleging that Dr. Movahed’s written report of Mr. Preston’s stress test was 
not available to her when she was treating Mr. Preston, and that the cardiology team 
had recommended and taken responsibility for scheduling Mr. Preston’s outpatient 
follow-up CTA.   
On 12 February 2016 plaintiff filed a second complaint (the Second Complaint) 
naming as defendants Dr. Movahed, Dr. Deepak Joshi, and Pitt County Memorial 
Hospital, Inc., d/b/a Vidant Medical Center (the Hospital).  Plaintiff’s Second 
Complaint, which again included her Rule 9(j) expert certification, alleged that 
defendant was negligent by, inter alia, failing to “accurately interpret and 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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communicate the findings and significance of diagnostic tests performed on Mr. 
Preston,” failing to “timely suggest and perform a full assessment and work-up to rule 
out life-threatening acute coronary artery disease for a patient at high risk for the 
disease, including but not limited to, cardiac catheterization,” and failing “to 
recommend a cardiology consult for Mr. Preston prior to his discharge from Vidant 
Medical Center with acute chest pain.”  On the same day the Second Complaint was 
filed, Dr. Toporoff submitted a second affidavit (his Second Affidavit) stating that he 
had reviewed the medical care and records and was willing to testify that the care 
provided by the named defendants failed to comply with the applicable standard of 
care.  Dr. Toporoff averred that the case materials were first provided to him in July 
of 2015 and that “[a]dditional materials were provided to [him] on October 12 and 
October 29, 2015 and on February 10, 2016.”  According to the affidavit, Dr. Toporoff’s 
stated that based on his review of the medical records and his training and 
experience,  
[i]t is my opinion that medical care provided to William 
Preston during his admission to Vidant Medical Center on 
February 3–4, 2014 for chest pain failed to comply with the 
applicable standard of care for the evaluation of a patient 
with chest and arm pain who presented with Mr. Preston’s 
signs, symptoms, and medical history. . . . I have expressed 
my willingness to testify to the above if called upon to do 
so.  
 
By consent order filed 14 March 2016, the two actions were consolidated for discovery 
and trial.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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During a subsequent deposition on 23 March 2017, Dr. Toporoff testified that 
he was critical of defendant’s interpretation and communication of the results of the 
nuclear stress test.  Dr. Toporoff stated that he had initially been unwilling to testify 
against defendant because he was not qualified to criticize defendant’s interpretation 
of the nuclear images from the test and that he “refused to be a nuclear cardiologist 
against him.”  Dr. Toporoff confirmed, however, that at the time he submitted his 
Second Affidavit he was comfortable stating that defendant “failed to meet the 
standard of care as it applies to a cardiologist interpreting a treadmill stress test.”   
On 16 June 2017, defendant filed a motion to dismiss pursuant to Rules 
12(b)(6), 9(j) and 41 of the North Carolina Rules of Civil Procedure.  On 15 September 
2017, Dr. Toporoff submitted a third affidavit (his Third Affidavit), stating that prior 
to the First Complaint he communicated to plaintiff’s counsel that he did not have 
sufficient information to state that defendant and/or Dr. Joshi clearly violated any 
standards of care.  However, Dr. Toporoff stated that following discovery answers 
served by Vidant Medical Center and Dr. Doctor regarding the communication of Mr. 
Preston’s stress test results by defendant and Dr. Joshi, he learned “that Dr. 
Movahed’s report was NOT made available to [Dr. Doctor] prior to Mr. Preston’s 
discharge.”  Dr. Toporoff averred that he informed plaintiff’s counsel on 12 February 
2016 that he was willing to testify that defendant and Dr. Joshi breached the 
applicable standard of care by “fail[ing] to interpret, diagnose, document and 
communicate to the ordering physician the presence of chest pain and ST wave 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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depression changes during Mr. Preston’s nuclear stress test that were consistent with 
ischemia; and failure to recommend an immediate cardiology consult for Mr. Preston 
prior to his discharge.”  Dr. Toporoff stated that he held these opinions “[s]ince [his] 
review of the totality of these medical records and documents in February in 2016.”   
At the hearing on the motion to dismiss on 18 September 2017, defendant 
argued that plaintiff failed to comply with Rule 9(j) because Dr. Toporoff could not 
reasonably be expected to qualify as an expert witness and was not willing to testify 
that defendant breached the applicable standard of care.  The trial court entered an 
order on 25 October 2016, in which it found, in pertinent part: 
22. 
Dr. Toporoff . . . admitted that Dr. Movahed’s 
involvement was limited to the interpretation of the 
nuclear stress test that was performed on Mr. Preston. 
 
. . . . 
 
24. 
Dr. Toporoff only agreed to testify in the Second 
Lawsuit 
if 
Plaintiff’s 
counsel 
retained 
a 
nuclear 
cardiologist. 
 
. . . . 
 
27. 
[A]s of the date the Second Lawsuit was filed, 
Plaintiff had no cardiologist competent or willing to testify 
against . . . Dr. Movahed. 
 
The trial court also found that plaintiff could not have reasonably expected Dr. 
Toporoff to qualify as an expert witness.  Accordingly, the trial court concluded that 
plaintiff failed to comply with Rule 9(j) and granted defendant’s motion to dismiss.  
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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On 3 November 2017, a Consent Order was entered on the parties’ Consent Motion 
to Sever the two cases for appeal.  Plaintiff appealed this case to the Court of Appeals.  
At the Court of Appeals,4 plaintiff argued, inter alia, that the trial court’s 
Findings 22, 24, and 27 were not supported by competent evidence and that the trial 
court erred in concluding that plaintiff failed to comply with Rule 9(j).  The court 
disagreed, first stating that the standard of review was de novo and that: 
[w]here, as here, “a trial court determines a Rule 9(j) 
certification is not supported by the facts, ‘the court must 
make written findings of fact to allow a reviewing appellate 
court to determine whether those findings are supported by 
competent evidence, whether the conclusions of law are 
supported by those findings, and, in turn, whether those 
conclusions 
support 
the 
trial 
court’s 
ultimate 
determination.’ ” 
 
Preston, 825 S.E.2d at 662 (quoting Estate v. Wooden ex rel. Jones v. Hillcrest 
Convalescent Ctr., Inc., 222 N.C. App. 396, 403 (2012)).   
Applying this standard, the court first addressed plaintiff’s challenge to 
Finding of Fact 22 and concluded that it was supported by the following exchange 
from Dr. Toporoff’s deposition: 
Q. 
You know that Dr. Movahed’s involvement in this 
case is the interpretation of the nuclear stress test that was 
performed on Mr. Preston?  You understand that; correct? 
 
A. 
Yes. 
 
                                            
4 Plaintiff entered into settlement agreements with Dr. Joshi and the Hospital and on 
plaintiff’s motions the Court of Appeals dismissed those parties from the appeal on 15 August 
2018 and 13 September 2018, respectively.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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Id. at 662.  While Plaintiff contended that “the nuclear stress test involves two parts: 
the exercise treadmill stress test and the nuclear heart images” and that “Dr. Toporoff 
was critical of Dr. Movahed’s interpretation of the . . . exercise treadmill portion, 
which revealed issues with Mr. Preston’s heart requiring immediate further testing,” 
the court determined that plaintiff’s explanation did not make the challenged finding 
erroneous because “[t]he well-established rule is that findings of fact by the trial court 
supported by competent evidence are binding on the appellate courts even if the 
evidence would support a contrary finding.”  Id. at 662 (quoting Scott v. Scott, 336 
N.C. 284, 291, 442 S.E.2d 493, 497 (1994)).   
 
The court next addressed plaintiff’s argument that Finding 24 was erroneous 
because Dr. Toporoff:  (1) opined in his Rule 9(j) affidavits that Preston’s medical care 
failed to comply with the standard of care and “expressed [his] willingness to testify 
to the above if called upon to do so”; and (2) testified when deposed that, at the time 
he signed his Second Affidavit prior to the filing of the Second Complaint, he “felt 
comfortable saying that Dr. Movahed failed to meet the standard of care as to the 
interpretation of the exercise treadmill test.”  Id. at 662.  The court determined that 
Dr. Toporoff’s deposition testimony, including his testimony that “he would not testify 
against Dr. Movahed unless [plaintiff] came up with a nuclear cardiologist” provided 
competent evidence directly supporting the trial court’s challenged finding, even if 
Dr. Toporoff’s Rule 9(j) affidavits or other deposition testimony could support a 
different finding.  Id. at 663.  Further, the court rejected plaintiff’s efforts to 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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distinguish between Dr. Toporoff’s opinions of defendant’s interpretation of the NST 
images as opposed to the results of the treadmill stress test.  See id. (“Plaintiff 
emphasizes Dr. Toporoff’s later deposition testimony in which he confirmed he “had 
opinions separate and apart from the NST images” and was “comfortable . . . when 
[he] did the 9(j) affidavit[ ] . . . saying that Dr. Movahed failed to meet the standard 
of care as it applies to a cardiologist interpreting a treadmill stress test[.]”).  According 
to the court: 
Dr. Toporoff’s statement that he “had opinions separate 
and apart from the NST images” was immediately followed 
by his confirmation that he “didn’t feel as confident 
expressing those [opinions] until [he] had some kind . . . of 
support for the NST images as well.”  Moreover, merely 
having an opinion does not indicate one’s willingness to 
testify as to that opinion.  Additionally, Dr. Toporoff’s 
confirmation that he was “comfortable . . . when [he] did 
the 9(j) affidavit . . . saying that Dr. Movahed failed to meet 
the standard of care as it applies to a cardiologist 
interpreting a treadmill stress test” was not an 
unequivocal assertion that he was “willing to testify” 
against Dr. Movahed.  Regardless of whether Dr. Toporoff 
had opinions or was comfortable saying something about 
Dr. 
Movahed 
regarding 
the 
treadmill-stress-test 
component of interpreting the NST, Dr. Toporoff’s 
testimony considered contextually establishes that his 
willingness to testify against Dr. Movahed in any capacity 
was conditioned upon having the support of a nuclear 
cardiologist who was competent and willing to testify 
against Dr. Movahed as to the nuclear-imaging component. 
 
Id. 
 
Next, the court addressed plaintiff’s challenge to Finding 27.  Having 
previously concluded that evidence supported the trial court’s finding that Dr. 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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Toporoff only agreed to testify if plaintiff retained a nuclear cardiologist, the court 
noted that the two nuclear cardiologists were consulted months after the Second 
Complaint was filed and after the statute of limitations had expired and concluded 
that Finding 27 was supported by competent evidence.  Id. at 663–64. 
 
Finally, the court reviewed whether the trial court’s findings support its 
conclusions and its ultimate decision to dismiss plaintiff’s complaint for substantive 
Rule 9(j) noncompliance.  In light of the findings that Dr. Toporoff was plaintiff’s only 
cardiologist who had reviewed Preston’s care before the Second Complaint was filed, 
that Toporoff only agreed to testify if plaintiff hired a nuclear cardiologist, and that 
plaintiff failed to consult with the other nuclear cardiologists she retained until 
months after she filed the Second Complaint, the court determined that the trial court 
correctly concluded that plaintiff’s Second Complaint failed to comply with Rule 9(j) 
because she had no cardiologist willing to testify against defendant at the time of 
filing.  Id. at 665.  In light of this conclusion, the court did not address the trial court’s 
determination that plaintiff failed to substantively comply with Rule 9(j)’s 
requirement that it was reasonable for plaintiff to expect Dr. Toporoff to qualify as 
an expert witness against defendant.  Id. at 665.   
 
Plaintiff filed a petition for discretionary review on the general issues of the 
appropriate legal standard to apply to a motion to dismiss on Rule 9(j) grounds and 
whether the Court of Appeals erred in failing to conduct a de novo review of the trial 
court’s order dismissing the complaint.  Defendant’s response to the petition indicated 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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their intent to present to this Court the further issue of whether Dr. Toporoff was 
qualified to testify against Dr. Movahed.  This Court allowed the petition on 14 
August 2019.  
Analysis 
 
After careful review of the record, we conclude that both of the lower courts 
erred in failing to view the evidence regarding Dr. Toporoff’s willingness to testify 
under Rule 9(j) in the light most favorable to plaintiff and that the Court of Appeals, 
in its de novo review, erred by deferring entirely to the findings of the trial court.   
 
 “Rule 9(j) serves as a gatekeeper, enacted by the legislature, to prevent 
frivolous malpractice claims by requiring expert review before filing of the action.”  
Vaughan v. Mashburn, 371 N.C. 428, 434, 817 S.E.2d 370, 375 (2018) (quoting Moore 
v. Proper, 366 N.C. 25, 31, 726 S.E.2d 812, 817 (2012)).  The rule provides, in pertinent 
part: 
Any complaint alleging medical malpractice by a health 
care provider pursuant to G.S. 90-21.11(2)a. in failing to 
comply with the applicable standard of care under G.S. 90-
21.12 shall be dismissed unless: 
 
(1) The pleading specifically asserts that the medical 
care and all medical records pertaining to the alleged 
negligence that are available to the plaintiff after 
reasonable inquiry have been reviewed by a person 
who is reasonably expected to qualify as an expert 
witness under Rule 702 of the Rules of Evidence and 
who is willing to testify that the medical care did not 
comply with the applicable standard of care; 
 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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N.C.G.S. § 1A-1, Rule 9(j) (2019).5  Thus, the rule prevents frivolous claims “by 
precluding any filing in the first place by a plaintiff who is unable to procure an expert 
who both meets the appropriate qualifications and, after reviewing the medical care 
and available records, is willing to testify that the medical care at issue fell below the 
standard of care.”  Vaughan, 371 N.C. at 435, 817 S.E.2d at 375. 
 
In Moore v. Proper, this Court addressed the manner in which a trial court 
should evaluate compliance with Rule 9(j), as well as the standard of review for a 
reviewing court on appeal.  There, the plaintiff filed a medical malpractice complaint 
against the defendants alleging that the defendants were “negligent in the 
performance of her tooth extraction and in failing to provide follow-up care.”  Moore, 
366 N.C. at 26, 726 S.E.2d at 814.  Following a deposition of the plaintiff’s Rule 9(j) 
certification expert, the defendants filed a motion for summary judgment pursuant 
to Rule 9(j).  The trial court granted the defendants’ motion and dismissed the 
                                            
5 The rule also provides that a complaint is in compliance if: 
 
(2) The pleading specifically asserts that the medical care and 
all medical records pertaining to the alleged negligence that are 
available to the plaintiff after reasonable inquiry have been 
reviewed by a person that the complainant will seek to have 
qualified as an expert witness by motion under Rule 702(e) of 
the Rules of Evidence and who is willing to testify that the 
medical care did not comply with the applicable standard of care, 
and the motion is filed with the complaint; or 
 
(3) The pleading alleges facts establishing negligence under the 
existing common-law doctrine of res ipsa loquitur. 
 
N.C.G.S. 1A-1, Rule 9(j). 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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plaintiff’s case for noncompliance with Rule 9(j), stating:  “no reasonable person would 
have expected [the plaintiff’s expert] to qualify as an expert witness under Rule 702.”  
Id. at 28, 726 S.E.2d at 815.  Following a split decision in the Court of Appeals 
reversing the trial court, the defendants appealed to this Court. 
 
The Court first addressed whether an expert must actually qualify under Rule 
702 in order to satisfy Rule 9(j)’s requirement that the certification expert “is 
reasonably expected to qualify as an expert witness under Rule 702.”  The Court noted 
that “Rule 9(j) . . . operates as a preliminary qualifier to ‘control pleadings’ rather 
than to act as a general mechanism to exclude expert testimony.”  Id. at 31, 726 
S.E.2d at 817.  Moreover, because of the presumption “that that the legislature 
carefully chose each word used,” and in order to “give every word of the statute effect,” 
the Court concluded: “we must ensure that the two questions are not collapsed into 
one. Id. at 31, 726 S.E.2d at 817.  Thus, while “[t]he trial court has wide discretion to 
allow or exclude testimony under” Rule 702, id. at 31, 726 S.E.2d at 817 (quoting 
State v. Bullard, 312 N.C. 129, 140, 322 S.E.2d 370, 376 (1984)), “the preliminary, 
gatekeeping question of whether a proffered expert witness is ‘reasonably expected 
to qualify as an expert witness under Rule 702’ is a different inquiry,” id. at 31, 726 
S.E.2d at 817 (citing N.C.G.S. § 1A-1, Rule 9(j)); see also id. at 31, 726 S.E.2d at 817 
(stating that “a trial court must analyze whether a plaintiff complied with Rule 9(j) 
by including a certification complying with the Rule before the court reaches the 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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ultimate determination of whether the proffered expert witness actually qualifies 
under Rule 702”).  
 
In addressing the Rule 9(j) inquiry, the Court explained that “[b]ecause Rule 
9(j) requires certification at the time of filing that the necessary expert review has 
occurred, compliance or noncompliance with the Rule is determined at the time of 
filing.”  Id. at 31, 726 S.E.2d at 817 (citations omitted).  The Court agreed with 
previous Court of Appeals precedent holding that “a court should look at ‘the facts 
and circumstances known or those which should have been known to the pleader’ at 
the time of filing,” id. at 31, 726 S.E.2d at 817 (quoting Trapp v. Maccioli, 129 N.C. 
App. 237, 241, 497 S.E.2d 708, 711 (1998)), “as any reasonable belief must necessarily 
be based on the exercise of reasonable diligence under the circumstances,” id. at 31, 
726 S.E.2d at 817 (citing Fort Worth & Denver City Ry. Co. v. Hegwood, 198 N.C. 309, 
317, 151 S.E. 641, 645 (1930)).  Additionally, the Court noted that “a complaint 
facially valid under Rule 9(j) may be dismissed if subsequent discovery establishes 
that the certification is not supported by the facts, at least to the extent that the 
exercise of reasonable diligence would have led the party to the understanding that 
its expectation was unreasonable.”  Id. at 31–32, 726 S.E.2d at 817 (citing Barringer 
v. Wake Forest Univ. Baptist Med. Ctr., 197 N.C. App. 238, 255, 677 S.E.2d 465, 477 
(2009); Ford v. McCain, 192 N.C. App. 667, 672, 666 S.E.2d 153, 157 (2008)).  The 
Court further explained: 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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Though the party is not necessarily required to know all 
the information produced during discovery at the time of 
filing, the trial court will be able to glean much of what the 
party knew or should have known from subsequent 
discovery materials.  But to the extent there are reasonable 
disputes or ambiguities in the forecasted evidence, the trial 
court should draw all reasonable inferences in favor of the 
nonmoving party at this preliminary stage of determining 
whether the party reasonably expected the expert witness 
to qualify under Rule 702.  When the trial court determines 
that reliance on disputed or ambiguous forecasted evidence 
was not reasonable, the court must make written findings 
of fact to allow a reviewing appellate court to determine 
whether those findings are supported by competent 
evidence, whether the conclusions of law are supported by 
those findings, and, in turn, whether those conclusions 
support the trial court’s ultimate determination.  We note 
that because the trial court is not generally permitted to 
make factual findings at the summary judgment stage, a 
finding that reliance on a fact or inference is not reasonable 
will occur only in the rare case in which no reasonable 
person would so rely. 
 
Id. at 32, 726 S.E.2d 817–18 (citations omitted).   
 
Applying this standard, the Moore Court—construing all disputes or 
ambiguities in the factual record in favor of the plaintiff—determined that plaintiff’s 
complaint complied with Rule 9(j) in that plaintiff reasonably expected her proffered 
expert to qualify under Rule 702.  Id. at 35, 726 S.E.2d at 819–20.  The Court 
expressed no opinion on whether the plaintiff’s expert would actually qualify under 
Rule 702 and “note[d] that, having satisfied the Rule 9(j) pleading requirements, 
plaintiff has survived the pleadings stage of her lawsuit and may, at the trial court’s 
discretion, be permitted to amend the pleadings and proffer another expert” in the 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
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event that her proffered expert later failed to qualify under Rule 702.  Id. at 36, 726 
S.E.2d at 820.   
 
While the Rule 9(j) issue in Moore arose in the context of a motion for summary 
judgment and focused specifically on whether the plaintiff’s expert was reasonably 
expected to qualify as an expert witness, we conclude that the analytical framework 
set forth in Moore applies equally to other Rule 9(j) issues in which “a complaint 
facially valid under Rule 9(j)” is challenged on the basis that “the certification is not 
supported by the facts.”  Id., 366 at 31–32, 726 S.E.2d at 817 (citing Barringer, 197 
N.C. App. at 255, 677 S.E.2d at 477).  For instance, where, as here, a defendant files 
a motion to dismiss under Rule 12(b)(6) challenging a plaintiff’s facially valid 
certification that the reviewing expert was willing to testify at the time of the filing 
of the complaint, the trial court must examine “ ‘the facts and circumstances known 
or those which should have been known to the pleader’ at the time of filing,” id. at 31, 
726 S.E.2d at 817 (quoting Trapp, 129 N.C. App. at 241, 497 S.E.2d at 711), and “to 
the extent there are reasonable disputes or ambiguities in the forecasted evidence, 
the trial court should draw all reasonable inferences in favor of the nonmoving party 
at this preliminary stage,” id. at 32, 726 S.E.2d 817–18 (citations omitted).  “When 
the trial court determines that reliance on disputed or ambiguous forecasted evidence 
was not reasonable, the court must make written findings of fact to allow a reviewing 
appellate court to determine whether those findings are supported by competent 
evidence.”  Id. at 32, 726 S.E.2d at 818 (citations omitted).   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-20- 
We stress that Rule 9(j) is unique and that because the evidence must be taken 
in the light most favorable to the plaintiff, the nature of these “findings,” and the 
“competent evidence” that will suffice to support such findings, differs from situations 
where the trial court sits as a fact-finder.  We do not view the legislature’s enactment 
of Rule 9(j) as intending for the trial court to engage in credibility determinations and 
weigh competent evidence at this preliminary stage of the proceedings.  See id. at 31, 
726 S.E.2d at 817 (stating that Rule 9(j) “operates as a preliminary qualifier to 
‘control pleadings’ rather than . . . as a general mechanism to exclude expert 
testimony” (citing Thigpen, 355 N.C. at 203–04, 558 S.E.2d at 166)); see also State v. 
Dew, 225 N.C. App. 750, 760, 738 S.E.2d 215, 222 (2013) (“[T]he credibility of and 
weight to be given to the expert’s testimony is a question for the jury rather than the 
trial court.” (citing Howerton v. Arai Helmet, Ltd., 358 N.C. 440, 460–61, 597 S.E.2d 
674, 687–88 (2004))).  Thus, it is erroneous to conclude, as the Court of Appeals did 
here with respect to the trial court’s findings regarding Dr. Toporoff’s willingness to 
testify, that a Rule 9(j) “finding” “supported by competent evidence [is] binding on the 
appellate courts even if the evidence would support a contrary finding.” Preston, 825 
S.E.2d at 662 (quoting Scott, 336 N.C. at 291, 442 S.E.2d at 497).   
 
Defendant here agrees that Moore supplies the appropriate standard for 
evaluating plaintiff’s compliance with Rule 9(j) but nevertheless contends that the 
factual record clearly demonstrates Dr. Toporoff’s unwillingness to testify such that 
there is no reasonable dispute or ambiguity in the evidence.  Defendant argues that 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-21- 
the evidence establishes that Dr. Toporoff was not willing to testify unless plaintiff 
retained a nuclear cardiologist and that plaintiff did not retain a nuclear cardiologist 
at the time of the filing of the Second Complaint.  Thus, defendant contends that the 
trial court’s finding that Dr. Toporoff was not willing to testify at the time of filing 
was supported by the evidence and the trial court’s conclusion that plaintiff’s 
complaint failed to comply with Rule 9(j) was supported by the findings.   
On the other hand, plaintiff argues that the trial court mistakenly interpreted 
evidence of Dr. Toporoff’s unwillingness to testify against defendant at the time of 
the First Complaint as evidence that he was unwilling to testify against defendant at 
the time of the Second Complaint (in which defendant was added to the lawsuit) and 
also failed to apprehend that a “nuclear stress test” contains separate and distinct 
parts: (1) the EKG treadmill test, about which Dr. Toporoff is undisputedly qualified 
to testify; and (2) interpretation of the nuclear images.  According to plaintiff, taking 
the evidence in the light most favorable to plaintiff, the factual record clearly 
demonstrates that after receiving new information in Dr. Doctor’s Answer following 
the filing of the First Complaint, Dr. Toporoff was willing at the time of the filing of 
the Second Complaint to testify against defendant without the need for any nuclear 
cardiologist on the basis that defendant failed to meet the standard of care as a 
cardiologist interpreting a treadmill stress test—specifically, by failing to accurately 
interpret and document the EKG treadmill test, failing to timely and effectively 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-22- 
communicate the results to the hospitalist, and failing to recommend a cardiac 
consult prior to Mr. Preston’s discharge.   
We conclude that taking the evidence in the light most favorable to plaintiff, 
including Dr. Toporoff’s affidavits and his deposition testimony, the factual record 
clearly supports a reasonable inference that at the time of the filing of the Second 
Complaint Dr. Toporoff was willing to testify that defendant failed to comply with the 
applicable standard of care as a cardiologist.   
 
Here, plaintiff’s compliance with Rule 9(j) is measured at the time of the filing 
of the Second Complaint on 12 February 2016, as that was when Dr. Movahed was 
added as a defendant in the action.  See Moore, 366 N.C. at 31, 726 S.E.2d at 817 
(“[C]ompliance or noncompliance with the Rule is determined at the time of filing.” 
(citations omitted)).  In his Second Affidavit, submitted at the time of the filing of the 
Second Complaint, Dr. Toporoff averred that: 
[I]t is my opinion that medical care provided to William 
Preston during his admission to Vidant Medical Center on 
February 3 – 4, 2014 for chest pain, failed to comply with 
the applicable standard of care for the evaluation of a 
patient with chest and arm pain who presented with Mr. 
Preston’s signs, symptoms and medical history.  I first 
expressed this opinion to Ms. Armstrong on August 1, 2015 
and I provided additional opinion on September 20, 2015, 
on October 28, 2015 and on February 9, 2016.  I have 
expressed my willingness to testify to the above if called 
upon to do so. 
 
The ambiguity in Dr. Toporoff’s willingness to testify involves his deposition 
testimony.  In Dr. Toporoff’s 23 March 2017 deposition, he had difficulty remembering 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-23- 
when he formed his opinions of defendant.  Dr. Toporoff testified that he had not 
formulated any opinions regarding defendant prior to the First Complaint in 2015, 
explaining that he told plaintiff he was unwilling to testify against defendant unless 
she retained a nuclear cardiologist: 
A: 
It’s coming back to me.  I think I had always 
been critical of Dr. Movahed and I told [plaintiff’s counsel] 
that I did not feel competent in criticizing him because I 
knew what would happen in the sense that he would put 
up these images and I would look like a fool trying to 
interpret the images.   
 
 
And I believe I said to her I would not add him to my 
lawsuit unless she got another nuclear cardiologist to 
interpret the images.  I did not want to get into an across-
the-table where he is highly competent in that field on 
paper and I have no business criticizing his summaries. 
 
Q. 
Because you’re not qualified as – 
 
A. 
Correct. 
 
Q. 
– a nuclear cardiologist? 
 
A. 
That’s how his name got added later.  I 
refused to be a nuclear cardiologist against him. 
 
Q. 
Sure. 
 
A. 
That, I think, is what happened. 
 
Q. 
Because you’re not a nuclear cardiologist? 
 
A. 
Absolutely. 
 
Q. 
So it would be inappropriate for you to render 
any opinions – 
 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-24- 
A. 
Right. 
 
Q. 
– regarding Dr. Movahed because of that. 
 
A. 
But that’s why his name was left out the first 
time. 
 
At different points later in the deposition, Dr. Toporoff testified:   
A. 
At the beginning, I just wanted to make it 
clear, because I remember a conversation I had with 
[Plaintiff's attorney], that I would not testify against Dr. 
Movahed unless she came up with a nuclear cardiologist 
because I did not want to be across from him where he’s 
talking about nuclear images and I have to say, I know 
nothing. And once we agreed that she would get somebody 
else, then I felt I could handle myself clinically. 
 
 
 
 
. . . . 
 
Q. 
I think you said earlier that you initially did 
not feel competent to give testimony as to Dr. Movahed, but 
you told [plaintiff’s counsel] that if she got a nuclear guy, 
then you would feel competent to give testimony and I’m 
not sure I understood why you said that. 
 
A. 
I anticipated that if it were just my testimony 
against [defendant], he would say I had no business in 
making any judgment about his readings and what he does 
with them, and he would be completely correct.   
 
 
But once I didn’t have to worry about 
anything about looking at this doughnut hole [the nuclear 
images] and what do you think of it, then I felt much, much 
more comfortable because it was a clinical situation purely. 
 
Q. 
All Right.  So you had opinions separate and 
apart from the NST images, but you didn’t feel as confident 
expressing those until you had some kind –  
 
A. 
Correct. 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-25- 
 
Q. 
-- of support for the NST images as well? 
 
A. 
Correct. 
 
While this testimony is ambiguous as to whether Dr. Toporoff’s condition that 
plaintiff retain a nuclear cardiologist continued beyond the time of the filing of the 
First Complaint, the testimony still appears to be focused on the time period prior to 
the filing of the First Complaint (i.e. “at the beginning”) and in it Dr. Toporoff 
expressed his concern that his criticisms of defendant were not sufficiently distinct 
from defendant’s interpretation of the nuclear images such that he was willing to 
testify against defendant as a “cardiologist” at that time—as Dr. Toporoff put it, he 
“refused to be a nuclear cardiologist against him.”  Significantly, we note that later 
in the deposition Dr. Toporoff testified as follows regarding the time of the filing of 
the Second Complaint when he submitted his Second Affidavit: 
Q. 
And going back [to] your testimony about your 
opinions about Dr. Movahed in this case, you explained to 
[defendant’s counsel] on the record that you were not 
comfortable 
testifying 
as 
to 
the 
nuclear 
imaging 
interpretation by Dr. Movahed. 
 
 
Were 
you 
comfortable 
and 
do 
you 
remain 
comfortable at the time – at this time when you did the 9(J) 
affidavit, [emphasis added] were you comfortable saying 
that Dr. Movahed failed to meet the standard of care as it 
applies to a cardiologist [emphasis added] interpreting a 
treadmill stress test? 
A. 
Yes. 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-26- 
This “cardiologist” distinction is significant as a full reading of Dr. Toporoff’s 
deposition, along with Dr. Toporoff’s third affidavit, taken in the light most favorable 
to plaintiff clearly supports the inference urged by plaintiff—that the nature of Dr. 
Toporoff’s opinions concerning defendant significantly changed when, following the 
filing of the First Complaint, he realized that Dr. Movahed’s written report of the 
nuclear stress test, which had been included in the medical files that he previously 
reviewed, had not actually been included in Mr. Preston’s medical chart—and 
therefore was not seen by Dr. Doctor—until after Mr. Preston was discharged from 
the hospital.   
Dr. Toporoff testified that he first reviewed defendant’s involvement in the case 
when he received the medical files in 2015 prior to the filing of the First Complaint, 
stating that “you couldn’t not see it when you were reviewing the entire case” and 
that he “didn’t understand why [defendant’s] report had not commented on two 
important issues during the nuclear study, namely the fact that the man had chest 
pain on the treadmill and that there were EKG changes that were either ignored or 
not noticed.”  Thus, at the beginning Dr. Toporoff was critical of defendant’s report as 
it related to Mr. Preston’s chest pain and the EKG tracings from the exercise portion 
of the stress test.  Dr. Toporoff noted that he “do[es] about 250 to 300 treadmills a 
year” and explained that two of the ways you can “flunk” a stress test are “if the test 
provokes chest pain” and if “EKG changes during the treadmill worsened . . . and 
fulfilled the criteria for a positive exercise treadmill test for myocardial ischemia.”  
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-27- 
Dr. Toporoff was also critical of the report’s suggestion that “one may consider a 
CTA,” a type of angiogram he described as an outpatient procedure that in most cases 
is “a week or two down the line, as it was in this case.”  This was the “wrong test,” 
according to Dr. Toporoff, as Mr. Preston needed an immediate “cardiologist consult,” 
which “would have led to a cardiac catheterization which is the test that he really 
needed.”   
According to Dr. Toporoff, the plan from the physician ordering the test was 
that if the nuclear stress test was normal, Mr. Preston would be discharged, and in 
his view the “stress test was clearly not normal”: 
A. 
The treadmill test was, in my judgment, 
completely abnormal and consistent with myocardial 
ischemia.  And he thought -- he indicated in the exercise 
physiology portion that he didn’t see any abnormality.  I 
think he was wrong.  
 
Similarly, the chest pain on the treadmill is a very 
important clinical feature that he did not mention in his 
final impression. 
 
However, Dr. Toporoff acknowledged that the phrase “chest pain during exercise” was 
included in the report, that the report did not rule out ischemia, and that the report 
did not characterize the test as “normal.”   
 
Significantly, much of Dr. Toporoff’s criticism was reserved not for the report 
itself, but on the fact that this report was not made available until after Mr. Preston’s 
discharge, and that in its place defendant failed to effectively communicate the 
significance of the results of the test to the attending doctor, Dr. Doctor.  Dr. Toporoff 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-28- 
testified that Mr. Preston’s death was caused by a “breakdown of the whole system,” 
that he “shouldn’t have gone home,” and that it started with defendant.  According to 
Dr. Toporoff:  
A. 
Well, it starts off with that Dr. Joshi is in his 
second day as a nuclear cardiology fellow, . . . . And in this 
particular week or day he was assigned to Dr. Movahed. 
 
 
Of all the people who read nuclear cardiology tests, 
it appears that they either typed their own reports right 
into the electronic medical record.   
 
 
. . . . Dr. Movahed is the only one who dictated his 
report, which means the hospital has to hire a 
transcriptionist and that report does not appear in the 
chart until the following day. 
 
 
. . . . [H]e doesn’t call the doctor.  He assigns Dr. 
Joshi on his second day to explain the nuclear findings to, 
in this case, Dr. Doctor because she was the hospitalist of 
record. 
 
Dr. Toporoff stated that the “report hit the chart February 5th at about 8:30 in the 
morning . . . and the patient was long gone,” and that the “patient was discharged 
before the report was in the chart and I think [that] was instrumental in allowing 
Mr. Preston to die.”  Dr. Toporoff further explained: 
A. 
Let me amplify.  If you’re dealing with an 
outpatient procedure, the guy isn’t that sick, he comes in.  
I’m not going to say that every one at our hospital is ready 
the same day.  You can do it a day or two later.  Maybe it’s 
not great medicine, but it’s nothing terrible.  But when a 
guy comes in through the emergency room and you rule out 
MI and he’s having chest discomfort, that report should be 
available that same day. 
 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-29- 
Q. 
And this is a report by a nuclear cardiologist? 
 
A. 
Yes. 
 
Q. 
Which you are not? 
 
A. 
I don’t think it matters whether I am or not.  
I know when a report should be due. 
 
In Dr. Toporoff’s view, given the information that defendant possessed, “especially 
since he knows when that report is going to be available on the computer, I think he 
should have picked up the telephone himself and called Dr. Doctor and said, You have 
a problem there.  I would get the consulting service to see this patient.”  As Dr. 
Toporoff put it, “to have a nuclear cardiology report that’s abnormal, you can’t just 
dictate it and walk away.  That’s wrong.”   
Further, Dr. Toporoff opined that it would not have been appropriate to 
delegate such a task to Dr. Joshi, stating “[w]hen a test is that abnormal, I think the 
physician of record should take no chances and should speak to the doctor himself 
personally.”  In that respect, Dr. Toporoff noted that Dr. Joshi’s note, which was 
added to the medical chart and received by Dr. Doctor before Mr. Preston’s discharge, 
made no mention of the fact that Mr. Preston experienced chest pain during the 
treadmill test or of any ST abnormalities.   
Thus, a significant portion of Dr. Toporoff’s criticism of defendant’s conduct 
was based not on the report that he received with the medical records back in 2015 
but rather on the fact that the report was not made available to the attending 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-30- 
hospitalist prior to Mr. Preston’s discharge.  As such, it reasonable to infer that while 
Dr. Toporoff was unwilling to testify against defendant purely on the basis of the 
report, part of which he acknowledged he was not qualified to address (the nuclear 
images) and other portions of which he was critical but also conceded did not 
characterize the nuclear stress test as normal, he was willing to testify that 
defendant’s failure to submit the report or otherwise communicate the results of the 
test to the hospitalist was a breach of the standard of care as a cardiologist.   
Dr. Toporoff clarified his opinions in his Third Affidavit submitted on 15 
September 2017, in which he averred: 
5)  In November of 2015, I signed an Expert Witness 
Affidavit regarding the hospitalist physicians.  Around 
that time, I communicated to [plaintiff’s counsel] that I did 
not have sufficient information to say that Dr. Movahed 
and/or Dr. Joshi had clearly violated any standards of care. 
 
6)  In February of 2016, I again spoke with [plaintiff’s 
counsel], who informed me that she had received additional 
information through discovery answers served by Vidant 
Medical Center and Dr. Neha Doctor[6] regarding the 
communication of Mr. Preston’s stress tests results by Drs. 
Movahed and Joshi. 
 
7)  Based on the representation by Dr. Doctor in those 
documents of the following information: that Dr. 
                                            
6 Dr. Doctor’s answer stated:  
 
[I]t is admitted that the medical records of Mr. Preston contain 
a report of the nuclear stress test which appears to have been 
prepared by Dr. Movahed, that this is a written document, which 
speaks for itself and is the best evidence of what is contained in 
the report, but it is denied that this written report was available 
to this Defendant at the time she provided care to Mr. Preston.   
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-31- 
Movahed’s report was NOT available to her prior to Mr. 
Preston’s discharge; that Dr. Movahed had specifically 
made recommendations to the hospitalists, and that Dr. 
Joshi communicated the results of the nuclear stress test 
with “cardiology’s” recommendation for an outpatient CT 
angiogram, I informed Ms. Armstrong I was willing to 
testify that Dr. Movahed and Dr. Joshi violated standards 
of care in their collaboration and treatment of Mr. Preston. 
 
8)  My criticisms of Drs. Movahed and Joshi include: 
failures to interpret, diagnose, document and communicate 
to the ordering physician the presence of chest pain and ST 
wave depression changes during Mr. Preston’s nuclear 
treadmill stress test that were consistent with ischemia, 
and failure to recommend an immediate cardiology consult 
for Mr. Preston prior to his discharge.  These are violations 
of the standard of care. 
 
9)  Since my review of the totality of these medical records 
and documents in February of 2016, I have held these 
opinions.  I expressed my willingness to testify regarding 
the standard of care that applied to Drs. Movahed and 
Joshi in their treatment and care of Mr. Preston to Ms. 
Armstrong in a phone call on February 12, 2016.  
 
In viewing the evidence in the light most favorable to plaintiff, we conclude 
that the evidence does not support the trial court’s findings that “Dr. Toporoff only 
agreed to testify in the Second Lawsuit if Plaintiff’s counsel retained a nuclear 
cardiologist” and that “as of the date the Second Lawsuit was filed, Plaintiff had no 
cardiologist competent or willing to testify against . . . Dr. Movahed.”7  Rather, the 
                                            
7 We conclude that the trial court’s Finding 22 (“Dr. Toporoff . . . admitted that Dr. 
Movahed’s involvement was limited to the interpretation of the nuclear stress test that was 
performed on Mr. Preston.”) is supported by the evidence.  In his deposition, Dr. Toporoff 
agreed with this statement; his opinion was that defendant, having been assigned to 
interpret the nuclear stress test, breached the standard of care by failing to accurately 
interpret it and communicate its results.      
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-32- 
factual record demonstrates that Dr. Toporoff was willing to testify against defendant 
at the time of the filing of the Second Complaint.  At a bare minimum, we are certain 
that any ambiguity in the evidence is not so unreasonable such that it should be 
resolved against plaintiff and result in a finding that plaintiff was unreasonable in 
her Rule 9(j) certification that Dr. Toporoff was willing to testify against defendant 
at the time of the filing of the Second Complaint.  Thus, the trial court’s conclusion 
that plaintiff failed to comply with the requirements of Rule 9(j) is unsupported by 
its findings to the extent that it is based on plaintiff’s reviewing expert’s purported 
unwillingness to testify against defendant.   
The trial court also determined that plaintiff could not have reasonably 
expected that Dr. Toporoff would qualify as an expert witness, an issue the parties 
briefed in the Court of Appeals and before this Court.  We hold that at the relevant 
time, again taking the evidence in the light most favorable to plaintiff, plaintiff’s 
expectation that Dr. Toporoff would qualify as an expert to testify in this case was 
reasonable.   
 
In that respect, we note that in declining to address whether plaintiff 
reasonably expected Toporoff to qualify under Rule 702, the language of the Court of 
Appeals suggested—though it is unclear—that the court was declining to address a 
question of whether Dr. Toporoff would actually qualify under Rule 702.  See Preston, 
825 S.E.2d at 664 (stating that “we need not address the sufficiency of evidence 
supporting that part of the finding as to whether Dr. Toporoff was competent to testify 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-33- 
in any capacity against Dr. Movahed” and that Rule 9(j) prevents “any filing in the 
first place by a plaintiff who is unable to procure an expert who both meets the 
appropriate qualifications and . . . is willing to testify” (quoting Vaughan, 371 N.C. at 
435 817 S.E.2d at 375)).  We reiterate in the interest of clarity that under Rule 9(j) 
“the preliminary, gatekeeping question of whether a proffered expert witness is 
‘reasonably expected to qualify as an expert witness under Rule 702’ is a different 
inquiry from whether the expert will actually qualify under Rule 702.”  Moore, 366 
N.C. at 31, 726 S.E.2d at 817 (citing N.C.G.S. § 1A-1, Rule 9(j)(1)).  Further, “to the 
extent there are reasonable disputes or ambiguities in the forecasted evidence, the 
trial court should draw all reasonable inferences in favor of the nonmoving party at 
this preliminary stage of determining whether the party reasonably expected the 
expert witness to qualify under Rule 702,” and “a finding that reliance on a fact or 
inference is not reasonable will occur only in the rare case in which no reasonable 
person would so rely.”  Id. at 32, 726 S.E.2d at 818 (citations omitted). 
 
The standards articulated in Moore apply here.  As summarized in that case, 
under Rule 702(b), there is a three-part test to qualify as an expert witness: 
(1) whether, during the year immediately preceding the 
incident, the proffered expert was in the same health 
profession as the party against whom or on whose behalf 
the testimony is offered; (2) whether the expert was 
engaged in active clinical practice during that time period; 
and (3) whether the majority of the expert's professional 
time was devoted to that active clinical practice. 
 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-34- 
Moore v. Proper, 366 N.C. at 33, 726 S.E.2d at 818 (footnote omitted).  The record in 
this case establishes that like Dr. Movahed, Dr. Toporoff is board-certified in internal 
medicine and cardiovascular disease.  During the relevant time period, and, in fact, 
for over forty years, Dr. Toporoff has practiced as a cardiologist, engaged in active 
clinical practice treating patients like Mr. Preston.  As part of this clinical work, Dr. 
Toporoff interprets hundreds of treadmill tests every year, and the treadmill test is 
the portion of the stress test relevant to the opinions Dr. Toporoff would testify to at 
trial.  There is no dispute that the majority of Dr. Toporoff’s professional time was 
devoted to his active clinical practice.  As such, this is not “the rare case” in which 
plaintiff’s reliance was unreasonable.  Id. at 31, 726 S.E.2d at 818.   
 
Defendant takes the position that because Dr. Toporoff is not a nuclear 
cardiologist and Dr. Movahed does have that specialized expertise, Dr. Toporoff could 
not qualify to testify against Dr. Movahed.  However, throughout the record as 
developed so far, Dr. Toporoff has been clear that he is not purporting to offer expert 
opinions about the nuclear imaging portion of the stress.  The rule only requires that 
an expert witness have experience performing the procedure that is the subject of the 
complaint and treats similar patients, not that both the defendant and the testifying 
witness have the exact same professional qualifications.  Just as a dentist can testify 
as an expert on the standards of care relevant to extracting a tooth in a case where 
the procedure at issue was actually performed by an oral and maxillofacial surgeon, 
a cardiologist who annually interprets hundreds of treadmill tests can testify about 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-35- 
the standards of care relevant to treadmill tests in a case where the treadmill test 
results were not properly handled by a nuclear cardiologist.  See, e.g., Roush v. 
Kennon, 188 N.C. App. 570, 575–76, 656 S.E.2d 603, 607 (2008).  Rule 9(j) is intended 
as a gatekeeping rule to prevent the prosecution of frivolous malpractice claims, not 
an endless maze of impossible hurdles to bar juries from hearing meritorious cases.  
Moore, 366 N.C. at 31, 726 S.E.2d at 817. 
Here plaintiff satisfied her Rule 9(j) responsibility by obtaining the opinion of 
a doctor who she reasonably expected to meet the three-part test for qualification 
under Rule 702(b) on the question of whether defendant violated the standard of care 
for cardiologists in reading Mr. Preston’s exercise treadmill stress test and EKG 
recordings and communicating those results to Mr. Preston’s ordering physicians.   
Conclusion 
 
In sum, we conclude that the trial court and the Court of Appeals erred in 
failing to view the factual record in the light most favorable to plaintiff.  The trial 
court’s findings that Dr. Toporoff was not willing to testify at the time of the filing of 
the Second Complaint are not supported by the evidence.  The affidavits and Dr. 
Toporoff’s deposition testimony demonstrate that after receiving new information in 
Dr. Doctor’s answer, Dr. Toporoff was willing to testify at the time of the filing of the 
Second Complaint that defendant breached the standard of care.  Further, it was 
reasonable for the plaintiff to conclude that Dr. Toporoff’s clinical practice as a 
cardiologist likely qualified him under Rule 702(b) to express expert opinions 
PRESTON V. MOVAHED 
 
Opinion of the Court 
 
 
-36- 
concerning Mr. Preston’s treadmill test.  This complaint should not be dismissed on 
Rule 9(j) grounds. We reverse the Court of Appeals and remand for further 
proceedings.    
REVERSED AND REMANDED. 
 
 
 
 
 
 
Justice NEWBY dissenting. 
The issue in this case is the standard by which an appellate court reviews a 
trial court’s dismissal of a complaint for noncompliance with N.C.G.S. § 1A-1, Rule 
9(j) (2019). In Moore v. Proper, this Court held that when a trial court dismisses a 
claim because it does not comply with Rule 9(j), appellate courts only ask whether 
competent evidence in the record supports the trial court’s findings of fact and those 
facts support its decision. 366 N.C. 25, 32, 726 S.E.2d 812, 818 (2012). The majority 
purports to clarify that standard from Moore, but in fact upends it altogether, 
replacing Moore’s appellate deferential standard of review with a de novo standard 
used to address summary judgment motions. It thus improperly converts this Court 
into a factfinder, removing that task from the trial court and subverting the trial 
court’s role as gatekeeper. Because the majority removes this critical and historic role 
from the trial court, it undermines the legislative purpose of Rule 9(j) to properly 
screen medical malpractice cases. 
The trial court determined that a clinical cardiologist was neither willing to 
testify nor reasonably expected to qualify to testify against an experienced nuclear 
cardiologist whose sole involvement in the case was the interpretation of a nuclear 
stress test. The clinical cardiologist by his own admission has not performed a nuclear 
stress test and cannot interpret nuclear stress test images. The question in this case 
is whether this Court should overrule the trial court’s factually supported decision. 
PRESTON V. MOVAHED 
 
Newby, J., dissenting 
 
-2- 
 
The majority disregards the trial court’s findings because it both misconstrues the 
facts and ignores the proper standard of review. It therefore undermines Rule 9(j) 
and Rule 702 by ignoring the requirement that testimony against specialists must 
come from like specialists, and instead effectively says “any doctor will do.” Because 
the trial court correctly granted the motion to dismiss, its decision should be upheld. 
I respectfully dissent. 
The General Assembly enacted Rule 9(j) to establish trial courts as gatekeepers 
in medical malpractice actions. Rule 9(j) provides that any medical malpractice action 
“shall be dismissed unless” the plaintiff’s medical records and care “have been 
reviewed by a person” who is (1) “reasonably expected to qualify as an expert witness 
under Rule 702 of the Rules of Evidence,” and (2) “willing to testify that the medical 
care did not comply with the applicable standard of care.” N.C.G.S. § 1A-1, Rule 
9(j)(1). The General Assembly passed these requirements to ensure that experts in 
medical malpractice actions would be “qualified practitioners of a competence similar 
to those of the practitioners who are the object of the suit.” Minutes, Meeting on H. 
636 & H. 730 Before the House Select Comm. on Tort Reform, 1995 Reg. Sess. (Apr. 
19, 1995). 
Rule 9(j) thus requires courts to consider whether a witness is reasonably 
expected to qualify to testify under Rule 702. Rule 702 allows expert testimony only 
if the witness has specialized knowledge through experience or other training, and: 
(1) the testimony is based on sufficient facts or data, (2) the testimony is the product 
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or reliable principles and methods, and (3) the witness has applied those principles 
and methods reliably to the facts of the case. For medical malpractice actions 
specifically, Rule 702 explains that if the defendant is a specialist, “a person shall not 
give expert testimony [against the defendant] on the appropriate standard of health 
care” unless the prospective witness “[s]pecialize[s] in the same specialty as the 
[defendant]; or [s]pecialize[s] in a similar specialty which includes within its specialty 
the performance of the procedure that is the subject of the complaint and ha[s] prior 
experience treating similar patients.” N.C.G.S. § 8C-1, Rule 702(b)(1)(a), (b) (2019) 
(emphases added).  
Thus, for a plaintiff to satisfy Rule 9(j), at the time she filed her complaint she 
must have retained a witness willing and competent to testify as to the specific 
specialized procedures involved in the defendant’s medical care. By requiring such a 
showing, “[t]he legislature’s intent was to provide a more specialized and stringent 
procedure for plaintiffs in medical malpractice claims through Rule 9(j)’s requirement 
of expert certification prior to the filing of a complaint.” Thigpen v. Ngo, 355 N.C. 198, 
203–04, 558 S.E.2d 162, 166 (2002). 
This Court, in Moore, described how courts should address motions to dismiss 
under Rule 9(j). It first spoke to the role of trial courts. In determining whether a 
claim complies with Rule 9(j), this Court said, “the trial court must look to all the 
facts and circumstances that were known or should have been known by the [plaintiff] 
at the time of filing.” 366 N.C. at 32, 726 S.E.2d at 818. The trial court can consider 
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evidence outside of the plaintiff’s affidavit, including evidence which comes to light 
after the affidavit is filed. Id. at 31, 726 S.E.2d at 817. This Court explained that if 
“there are reasonable disputes or ambiguities in the forecasted evidence, the trial 
court should draw all reasonable inferences in favor of the nonmoving party at this 
preliminary stage of determining whether the party reasonably expected the expert 
witness to qualify under Rule 702.” Id. at 32, 726 S.E.2d at 818. Though only in the 
“rare case” will “the trial court determine[ ] that reliance on disputed or ambiguous 
forecasted evidence was not reasonable,” in such a case “the court must make written 
findings of fact . . . .” Id. at 32, 726 S.E.2d at 818. Moore thus recognized the unique 
capacity of the trial court as factfinder, directing that court to weigh reasonably 
disputed evidence in favor of the nonmoving party, but recognizing the trial court 
may determine in some cases that reliance on disputed or ambiguous forecasted 
evidence is unreasonable. 
Moore then explained the distinct role of appellate courts on appeal of a trial 
court’s Rule 9(j) dismissal. First, an appellate court must determine whether the trial 
court’s factual findings are supported by “competent evidence.” Id. at 32, 726 S.E.2d 
at 818. Second, if the factual findings are supported by competent evidence, the 
appellate court must determine whether the findings support the trial court’s 
conclusion that the complaint failed to comply with Rule 9(j). Id. Thus, though Moore 
requires trial courts to construe reasonably disputed evidence in the plaintiff’s favor, 
it directs appellate courts to uphold trial courts’ dismissals under a deferential 
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standard—when competent evidence can be found to support the decision.  
This is the second of two lawsuits filed by plaintiff.1 The current action was 
filed against Dr. Movahed, Dr. Joshi, and the hospital. Doctor Movahed is a board-
certified nuclear cardiologist, the head of his department, and an instructor of nuclear 
cardiology fellows. Doctor Joshi was a clinical cardiologist seeking to become board 
certified in nuclear cardiology and therefore was working as a fellow under Dr. 
Movahed. The defendants moved to dismiss the claims for failure to comply with Rule 
9(j). In response to the motion, plaintiff argued that Dr. Toporoff was qualified and 
willing to criticize Dr. Movahed at the time the lawsuit was filed. 
With this background, the trial court dismissed plaintiff’s complaints against 
all the defendants for noncompliance with Rule 9(j). Regarding Dr. Movahed, it found 
the following: that “Dr. Toporoff admitted that he is not a nuclear cardiologist, and 
has never interpreted nuclear stress tests”; that “Dr. Toporoff also testified that he 
had no business criticizing and did not feel competent criticizing Dr. Movahed’s 
interpretation of the [nuclear stress test]”; and that “Dr. Toporoff only agreed to 
testify in the [lawsuit against Dr. Movahed] if Plaintiff’s counsel retained a nuclear 
cardiologist.” The court thus concluded as a matter of law that plaintiff’s complaint 
failed to comply with Rule 9(j) because at the time of filing the lawsuit plaintiff had 
                                            
1 The first action was filed against several hospital defendants and the hospitalists, 
including Dr. Prodduturvar and Dr. Doctor. 
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no expert competent and willing to testify against the defendants.2 
The Court of Appeals agreed with the trial court, reaching only the issue of Dr. 
Toporoff’s willingness to testify. It properly performed its appellate role as set out in 
Moore, holding that the trial court’s finding that Dr. Toporoff was not willing to testify 
against Dr. Movahed at the time the complaint was filed was supported by competent 
evidence. Preston v. Movahed, 825 S.E.2d 657, 665 (N.C. Ct. App. Mar. 5, 2019). 
Applying the standard of review set out by Moore, this Court should affirm the 
trial court’s dismissal of plaintiff’s claim for noncompliance with Rule 9(j). The 
evidence in this case shows that at the time the complaint was filed, plaintiff could 
not have reasonably expected Dr. Toporoff to qualify to testify against Dr. Movahed 
regarding either the interpretation of the nuclear stress or the communication of the 
test results, and that Dr. Toporoff was not willing to do so. 
Doctor Toporoff was neither able nor willing to testify regarding Dr. Movahed’s 
interpretation of the nuclear stress test as a whole. Doctor Toporoff’s testimony shows 
that he is not a nuclear cardiologist like Dr. Movahed, that he understood that Dr. 
Movahed’s only role in the case was to interpret the decedent’s nuclear stress test, 
that he does not interpret nuclear cardiology images like those generated by the 
nuclear stress test, and that he does not feel competent to do so. Doctor Toporoff 
                                            
2 Plaintiff appealed and subsequently settled with the hospital and Dr. Joshi, 
leaving only the action against Dr. Movahed. 
 
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explained that before the action was filed, he likely told plaintiff that he would not 
comment on the nuclear stress test images but would only comment on the “review of 
the summary” of Dr. Movahed’s report, as well as Dr. Movahed’s communication of 
that report. He then explained that he told plaintiff he would not testify against Dr. 
Movahed at all unless plaintiff also retained a nuclear cardiologist to interpret the 
nuclear stress test images. Indeed, he admitted that he “ha[d] no business criticizing 
[Dr. Movahed’s] summaries” of nuclear stress test images. 
Rule 702(b)(2)(a) specifically requires an expert witness to have the same or 
substantially the same specialty as the defendant against whom the witness intends 
to testify. Doctor Movahed’s role was limited to the interpretation of the nuclear 
stress test, a role that includes interpreting nuclear stress test images, which Dr. 
Toporoff admitted he cannot do. Doctor Toporoff also admitted that he is not, and 
never has been, a nuclear cardiologist. Clearly plaintiff should have been aware that 
a clinical cardiologist like Dr. Toporoff would not qualify to testify against a nuclear 
cardiologist regarding a nuclear stress test that only a nuclear cardiologist is able to 
interpret. Understanding Dr. Toporoff’s limitations and his express concerns, 
plaintiff did eventually identify two nuclear cardiologists willing to serve as expert 
witnesses. But neither of them had reviewed the medical care at issue at the time of 
the filing of the complaint against Dr. Movahed. Plaintiff therefore should have been 
aware at time of filing that a nuclear cardiologist would be required to testify against 
another nuclear cardiologist whose involvement was limited to the interpretation of 
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the nuclear stress test. However, at the time the complaint was filed, plaintiff did not 
have a nuclear cardiologist willing to testify. 
Plaintiff nevertheless argues that, despite the unified nature of reading a 
nuclear stress test, the interpretation of the test can be broken into its component 
parts and criticized piecemeal. Thus, plaintiff asserts that a nuclear cardiologist is 
not necessary to criticize the care of another nuclear cardiologist. This approach is 
exactly what Rule 9(j) and Rule 702 are intended to prevent. It violates the plain 
language of Rule 702 which requires a specialist with the same subspecialty who is 
familiar with the procedure. Whether a test conducted by a specialist can be broken 
into component parts and criticized in this manner itself requires an expert in that 
field rendering that opinion. It is not something that a court can simply find without 
expert testimony. 
Specifically, plaintiff contends that Dr. Toporoff was willing and qualified to 
testify as to the EKG portion of the treadmill test. A clinical cardiologist, however, is 
not qualified to criticize how a nuclear cardiologist should utilize an EKG in isolation 
from the nuclear images. The majority concedes that Dr. Movahed’s involvement in 
this case was limited to the interpretation of the nuclear stress test only. And, as Dr. 
Toporoff concedes, the nuclear stress test involves reading together both the treadmill 
EKG and the nuclear imaging. Therefore, a complete interpretation of a nuclear 
stress test requires an understanding of the integration of both of these components. 
If Dr. Toporoff could not testify regarding an essential component of that test, the 
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nuclear images, plaintiff could not reasonably believe his testimony would likely 
“assist the trier of fact to understand the evidence or to determine a fact in issue” as 
Rule 702 requires. See N.C.G.S. § 8C-1, Rule 702(a). Of course, Dr. Toporoff’s own 
testimony supports this conclusion, as he said he would not feel comfortable testifying 
even about the EKG portion of the test unless plaintiff retained an expert to testify 
to the nuclear imaging portion as well. Doctor Toporoff’s reluctance to testify on this 
point goes hand in hand with the unlikelihood of his qualifying to do so; he did not 
want to testify against Dr. Movahed unless a nuclear cardiologist did as well because, 
in Dr. Toporoff’s words, “I did not want to get into an across-the-table where [Dr. 
Movahed] is highly competent in that field on paper and I have no business criticizing 
his summaries.” 
Finally, Dr. Toporoff was not in a position to testify regarding Dr. Movahed’s 
communication of the nuclear stress test results. For nuclear stress tests, typically 
the primary care doctor is the one who orders the test, and only does so once he or 
she rules out acute coronary artery syndrome. The nuclear cardiologist is not present 
when the nuclear stress test is conducted. The nuclear cardiologist’s only role is to 
later interpret the results of the nuclear stress test, which, as Dr. Movahed has 
explained, involves “just sitting in a dark room reading the nuclear.” Once he has 
interpreted the nuclear stress test, which Dr. Toporoff cannot do, the results are 
communicated to the hospitalist. In this case, consistent with the school’s protocol for 
teaching physicians, he communicated the results of the nuclear stress test to Dr. 
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Joshi while he instructed him on how to interpret the nuclear stress test images. The 
standard practice, Dr. Movahed explained, is that, as part of the nuclear cardiology 
training, the fellow communicates the test results to the hospitalist—the physician 
in charge of the patient. The hospitalist sets up any additional visits and testing with 
the patient. Doctor Movahed testified that when he communicates his results to the 
fellow, he typically recommends that, in cases of an abnormality like the decedent’s, 
a CTA be conducted on the patient immediately after discharge from the hospital. 
Doctor Toporoff admitted that he is not critical of the role of Dr. Joshi. Thus, if 
Dr. Toporoff is critical of the method of communication, he is critical of the 
communication protocol, not of Dr. Movahed. Plaintiff, however, has not put forth 
evidence that Dr. Toporoff is competent to testify about a nuclear cardiologist’s 
communication protocol in this teaching hospital. Doctor Toporoff has no special 
knowledge about whether nuclear stress test results should be communicated to a 
nuclear cardiology fellow, to the hospitalist, or to someone else. It is not enough 
simply to state that Dr. Toporoff is a cardiologist. At the very least, plaintiff must 
provide a witness who is familiar with proper communication protocols for nuclear 
cardiologists operating in the role of teaching physician; and plaintiff did not do so.  
Competent evidence thus supports the trial court’s conclusion that plaintiff 
had provided no witness willing to testify against Dr. Movahed and reasonably 
expected to qualify to do so. Doctor Toporoff, as a clinical cardiologist, was in no place 
to criticize Dr. Movahed’s interpretation of the nuclear stress test or Dr. Movahed’s 
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communication of that interpretation. Doctor Movahed is well-versed in a narrow 
specialty in which Dr. Toporoff does not have experience. Testimony from such a 
person is of the exact sort the General Assembly hoped to screen out when it enacted 
Rule 9(j). 
The majority goes astray from the very foundation of its analysis because it 
upends the standard of review this Court established in Moore. Its approach places 
the appellate court into the role of the trial court. If this Court in Moore intended the 
appellate court to review de novo the trial court’s dismissal, it would have said so. 
Indeed, if the majority were right that appellate courts can simply find their own 
facts to overrule trial courts’ Rule 9(j) decisions, that begs the question of why this 
Court in Moore required trial courts to make factual findings and conclusions of law 
at all. The appellate courts would only need a trial court record to review.  
Instead, Moore instructed appellate courts to operate under a deferential 
standard. It said that in the rare case in which the plaintiff’s reliance on disputed or 
ambiguous evidence was unreasonable, “the [trial] court must make written findings 
of fact to allow a reviewing appellate court to determine whether those findings are 
supported by competent evidence, whether the conclusions of law are supported by 
those findings, and, in turn, whether those conclusions support the trial court's 
ultimate determination.” 366 N.C. at 32, 726 S.E.2d at 818. Moore’s approach 
comports with the underlying intent of Rule 9(j) to screen frivolous and unsupported 
medical malpractice suits. The rule cannot meaningfully accomplish this purpose 
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unless trial courts may weigh the facts to determine whether the two central 
requirements of the rule are satisfied.  
By upending the Moore standard, the majority removes the trial court from its 
gatekeeping function, reassigning that role to the appellate court, finding its own 
facts and ignoring the findings and conclusions of the court most suited to make such 
determinations. Under the proper standard of review, the evidence in this case 
supports the trial court’s findings of fact that in turn support its conclusion that at 
the time the action was filed, Dr. Toporoff was neither willing to testify against Dr. 
Movahed nor reasonably expected to qualify to do so. 
I respectfully dissent.