Title: Jackson v. Qureshi
Citation: N/A
Docket Number: 080502
State: Virginia
Issuer: Virginia Supreme Court
Date: January 16, 2009

PRESENT:  All the Justices 
INEZ JACKSON, ADMINISTRATRIX OF THE  
ESTATE OF JAMES M. JACKSON, DECEASED  
 
v.  RECORD NO. 080502 
OPINION BY JUSTICE CYNTHIA D. KINSER 
 
 
 
January 16, 2009 
FAIQA AFTAB QURESHI, M.D., ET AL.  
 
FROM THE CIRCUIT COURT OF THE CITY OF NORFOLK 
Karen J. Burrell, Judge 
 
In this wrongful death action, the sole issue is whether a 
plaintiff’s proffered medical expert witness satisfied the 
criteria of Code § 8.01-581.20 to testify on the standard of 
care in the defendant’s specialty.  Because we find that the 
record clearly demonstrates the witness met the statutory 
“knowledge” requirement and “active clinical practice” 
requirement, see Wright v. Kaye, 267 Va. 510, 518, 593 S.E.2d 
307, 311 (2004), and was therefore qualified to testify as an 
expert with regard to the medical procedure at issue, we will 
reverse the circuit court’s judgment excluding the medical 
expert witness’ testimony. 
BACKGROUND 
The only issue before us concerns the question whether an 
expert witness was qualified to testify.  Therefore, “we need 
recite only those facts necessary to our resolution of the 
appeal.”  Dagner v. Anderson, 274 Va. 678, 681, 651 S.E.2d 640, 
641 (2007).  Accord Budd v. Punyanitya, 273 Va. 583, 587, 643 
S.E.2d 180, 181 (2007); Molchon v. Tyler, 262 Va. 175, 180, 546 
S.E.2d 691, 695 (2001). 
Inez Jackson, (Jackson), administratrix of the estate of 
James M. Jackson, deceased, (infant Jackson), filed a wrongful 
death action against Faiqa Aftab Qureshi, M.D., and her 
employer, Children’s Specialty Group, PLLC.  Jackson alleged, 
among other things, that Dr. Qureshi, while acting within the 
scope of her employment, negligently discharged infant Jackson 
and failed to admit him to inpatient hospital care when the 
infant presented at an emergency room with signs of respiratory 
distress and/or pertussis.1  She claimed that, as a direct and 
proximate result of Dr. Qureshi’s failure to comply with the 
applicable standard of care, infant Jackson ultimately died from 
pertussis and other complications caused by the infection.  
Finally, Jackson asserted that, during all times relevant to the 
claim, Dr. Qureshi “was a physician licensed to practice 
medicine in the Commonwealth . . . and was engaged in the 
practice of pediatric emergency medicine and/or pediatric 
medicine.” 
During discovery, Jackson identified John F. Modlin, a 
physician licensed in New Hampshire and board certified in 
pediatrics and pediatric infectious diseases, as her only 
                     
1 Pertussis, also known as whooping cough, is a highly 
contagious disease caused by the bacterium Bordetella pertussis. 
 
2
standard of care expert.  Prior to trial, the defendants moved 
the circuit court to exclude Dr. Modlin’s testimony as an expert 
witness on the standard of care.  The parties agreed that the 
circuit court could decide the motion by using Dr. Modlin’s 
deposition testimony and voir dire testimony elicited at a 
previous trial.2  Jackson also admitted into evidence a letter 
from the Commonwealth of Virginia Department of Health 
Professions, certifying “Dr. Modlin’s credentials meet the 
educational and examination requirements for licensure in 
Virginia.”  Jackson further agreed that if the defendants 
prevailed on the motion to exclude Dr. Modlin’s testimony, she 
would not name a replacement standard of care expert and “the 
case would come to a close.” 
Turning now to the testimony considered by the circuit 
court, Dr. Modlin, during his voir dire direct examination, 
first testified about his qualifications.  Dr. Modlin has been a 
professor of pediatric medicine at Dartmouth Medical School for 
the past 15 years.  He has served as chairman of the pediatric 
department for approximately seven years and also has worked as 
a physician with the infectious disease group at the Dartmouth 
                     
2 Prior to filing the instant action, Jackson had filed an 
identical wrongful death action but had taken a voluntary 
nonsuit during argument on the defendants’ motion to preclude 
Dr. Modlin from testifying.  At the trial on the nonsuited 
action, testimony was elicited from Dr. Modlin during the voir 
dire to qualify him as an expert witness. 
 
3
Hitchcock Medical Center.  Dr. Modlin explained that, as 
chairman of the department of pediatrics and as a medical 
director of the Children’s Hospital at Dartmouth Hitchcock 
Medical Center, he has responsibility for both clinical and 
academic missions. 
With regard to his clinical responsibilities, Dr. Modlin 
testified that he spends about 25 to 30 percent of his time in 
direct patient care, divided between two areas, “one as an 
infectious disease physician,” and the other “in a general 
pediatric clinical position.”  He explained that, in the latter 
setting, he has direct responsibility for patient care of 
children admitted to “a general pediatric ward,” and that many 
of those patients are infectious disease patients.  Dr. Modlin 
testified that the pediatric ward admits from five to thirteen 
patients per day and that he has “direct responsibility for all 
of those patients.”  According to Dr. Modlin, a child may be 
admitted to the pediatric ward through several different routes: 
They may be admitted directly from the outside, where 
they do not pass through the emergency room.  There 
will be other patients who will first come to the 
emergency room, and because they are sick require 
admission and will be directly admitted to the ward. 
 
 
We at Dartmouth have what we call an urgent care 
clinic, where many of the pediatric patients when they 
first arrive at the emergency room are so called 
triaged by the nurses.  They are evaluated, and if 
they don’t have a medical condition that puts them at  
very high risk where their life is clearly being 
threatened right then and there, most of the patients 
 
4
who are sick are actually sent up to our urgent care 
clinic. 
 
 
So, quite a bit of the care that I provide in the 
acute care setting actually is done in the urgent care 
clinic.  Again, it’s mostly in the setting of 
supervising pediatric residents and medical students 
who are maybe providing direct care, but . . . I would 
have ultimate responsibility for the outcome for those 
patients. 
 
Dr. Modlin testified at length concerning his knowledge of 
the infectious disease, pertussis.  He responded affirmatively 
when asked if he is “familiar with the standard of care for a 
reasonably prudent pediatrician physician in the Commonwealth of 
Virginia as to the care and treatment of those who present with 
respiratory problems and/or pertussis.” 
During cross-examination, Dr. Modlin admitted he is not 
board certified in pediatric emergency medicine and does not 
present himself as an expert in “pediatric emergency department 
medicine.”  He further admitted that he has not worked in an 
emergency room department since the early 1980s, and that the 
hospital in which he currently works does not have a separate 
emergency department for children.  Dr. Modlin, however, 
testified that he “would feel quite confident to deal with most 
any infectious disease that presented to an emergency department 
and . . . that [he] could render an . . . expert opinion, 
regarding any infectious disease that might show up in the 
[emergency department].” 
 
5
Dr. Modlin admitted that, during the past five years, he 
has not been called upon to diagnose a single patient with 
pertussis in an emergency room setting.  However, Dr. Modlin 
pointed out that he has treated such patients in the urgent care 
clinic and that this setting is “very similar to an emergency 
room setting.” 
Dr. Modlin’s deposition, which was taken approximately a 
month before the first trial, provided much of the same 
information.  When asked about the clinical activities that 
occupy 25 to 30 percent of his time, Dr. Modlin responded, “I 
see patients principally in the inpatient setting.  I see 
infectious disease consultations, both adult and pediatric 
infectious disease consultations; and I also maintain a limited 
pediatric infectious disease outpatient practice.”  Dr. Modlin 
testified that he does see patients in the emergency department 
on a consultation basis, but admitted that he “actually [does 
not] work as an emergency room physician.”  He further admitted 
that he is “not trained or board certified in emergency 
medicine.”  Dr. Modlin, however, testified, “I believe that all 
pediatricians who care for acutely ill children, regardless of 
whether they are [emergency department] physicians or pediatric 
[infectious disease] physicians or general pediatricians should 
appreciate how pertussis can present in an infant.” 
 
6
Also during his deposition, Dr. Modlin made it clear that 
his “only concern regarding the standard of care [is that infant 
Jackson] should have been admitted to the hospital.”  When asked 
whether his “sole opinion” is that “the standard of care under 
the circumstances presented [was] such that the infant . . . 
should have been admitted to the hospital,” Dr. Modlin answered, 
“Correct.” 
After considering the evidence and oral arguments, the 
circuit court granted the defendants’ motion.  The circuit 
court, in light of the stipulation reached between the parties, 
then ordered the case dismissed with prejudice.  Jackson appeals 
from the circuit court’s judgment. 
DISCUSSION 
The sole issue on appeal is whether the circuit court 
abused its discretion by holding that Dr. Modlin was not 
qualified to testify as an expert on the standard of care.  “The 
question whether a witness is qualified to testify as an expert 
is largely within the sound discretion of the trial court.”  
Lloyd v. Kime, 275 Va. 98, 108, 654 S.E.2d 563, 569 (2008) 
(internal quotations omitted); accord Perdieu v. Blackstone 
Family Practice Ctr., 264 Va. 408, 418, 568 S.E.2d 703, 709 
(2002).  “ ‘A decision to exclude a proffered expert opinion 
will be reversed on appeal only when it appears clearly that the 
witness was qualified.’ ”  Perdieu, 264 Va. at 418, 568 S.E.2d 
 
7
at 709 (quoting Noll v. Rahal, 219 Va. 795, 800, 250 S.E.2d 741, 
744 (1979)); see also Sami v. Varn, 260 Va. 280, 284, 535 S.E.2d 
172, 174 (2000) (“we will reverse a holding that a witness is 
not qualified to testify as an expert when it appears clearly 
from the record that the witness possesses sufficient knowledge, 
skill, or experience to make him competent to testify as an 
expert on the subject matter at issue”). 
In a medical malpractice action, the qualification of a 
witness as an expert on the standard of care is governed by Code 
§ 8.01-581.20, which states in relevant part: 
Any physician . . . who is licensed to practice in 
Virginia shall be presumed to know the statewide 
standard of care in the specialty or field of medicine 
in which he is qualified and certified.  This 
presumption shall also apply to any physician who is 
licensed in some other state of the United States and 
meets the educational and examination requirements for 
licensure in Virginia. . . .  An expert witness who is 
familiar with the statewide standard of care shall not 
have his testimony excluded on the ground that he does 
not practice in this Commonwealth.  A witness shall be 
qualified to testify as an expert on the standard of 
care if he demonstrates expert knowledge of the 
standards of the defendant’s specialty and of what 
conduct conforms or fails to conform to those 
standards and if he has had active clinical practice 
in either the defendant’s specialty or a related field 
of medicine within one year of the date of the alleged 
act or omission forming the basis of the action. 
 
Under this statute, a physician is presumed to know the 
statewide standard of care in the physician’s specialty or field 
of medicine either if the physician is licensed to practice in 
Virginia or “[i]f the physician is licensed out-of-state, but 
 
8
meets the educational and examination requirements of the 
statute.”  Lloyd, 275 Va. at 109, 654 S.E.2d at 569.  The 
statutory presumption applied to Dr. Modlin.  Although he was 
not licensed to practice in Virginia, Dr. Modlin’s credentials 
satisfied the educational and examination requirements for 
licensure in the Commonwealth, according to the letter from the 
Commonwealth of Virginia Department of Health Professions.  
Thus, it was presumed that Dr. Modlin knew the statewide 
standard of care in his specialties of pediatrics and pediatric 
infectious diseases. 
Even with the benefit of the presumption, “to qualify as an 
expert witness on the standard of care, the witness must have 
expert knowledge on the standard of care in the defendant’s 
specialty and an ‘active clinical practice in either the 
defendant’s specialty or a related field of medicine within one 
year of the date of the alleged act or omission forming the 
basis of the action.’ ”  Id. (quoting Code § 8.01-581.20).  We 
have previously referred to these two requirements as the 
“knowledge” requirement and the “active clinical practice” 
requirement.  Wright, 267 Va. at 518, 593 S.E.2d at 311. 
With regard to the “knowledge” requirement, Jackson, as the 
proponent of the expert witness, had the initial burden to 
“show, among other things, that the ‘specialty or field of 
medicine in which [Dr. Modlin] is qualified and certified’ is 
 
9
the same as [Dr. Qureshi’s] specialty or a related field of 
medicine.”  Lloyd, 275 Va. at 109, 654 S.E.2d at 569-70 (quoting 
Code § 8.01-581.20).  In other words, Jackson had to demonstrate 
that Dr. Modlin’s “area of qualification and certification” in 
pediatrics and pediatric infectious diseases “had certain 
overlapping medical practices and similar standards of care 
with” Dr. Qureshi’s “area of qualification and certification” in 
pediatric emergency medicine.  Id. at 110, 654 S.E.2d at 570. 
This requirement can be shown by evidence that the standard of 
care, as it relates to the alleged negligent act or treatment, 
is the same for the proffered expert’s specialty as it is for 
the defendant doctor’s specialty.  Sami, 260 Va. at 283-84, 535 
S.E.2d at 174; see also Griffett v. Ryan, 247 Va. 465, 472-73, 
443 S.E.2d 149, 153-54 (1994) (holding that an internist was 
qualified to testify as an expert because the evidence 
demonstrated that the standard of care applicable to the 
internist did not vary from the standard of care in the 
defendant’s specialty, gastroenterology, a subspecialty of 
internal medicine). 
In Sami, this Court held that a trial court abused its 
discretion by holding that an expert witness whose specialty was 
in obstetrics-gynecology did not demonstrate knowledge of the 
standard of care applicable to the defendant’s specialty in 
 
10
emergency medicine.  260 Va. at 284, 535 S.E.2d at 174.  We 
explained: 
[The expert’s] lack of knowledge regarding certain 
procedures of emergency medicine might disqualify him 
from rendering expert testimony as to those 
procedures, but that lack of knowledge does not 
preclude him from giving expert testimony on 
procedures which are common to both emergency medicine 
and the field of obstetrics-gynecology and are 
performed according to the same standard of care.  
 
Id. at 284, 535 S.E.2d at 174; see also Wright, 267 Va. at 522, 
593 S.E.2d at 313 (whether an expert has knowledge of the 
standard of care for a defendant’s specialty must be determined 
by reference to the relevant medical procedure at issue in a 
particular case). 
Applying these principles, we conclude that Dr. Modlin 
satisfied the “knowledge” requirement of Code §  8.01-581.20.  
It is undisputed that the only relevant medical procedure at 
issue is Dr. Qureshi’s decision not to admit infant Jackson to 
inpatient hospital care when the infant presented to the 
emergency room showing signs of respiratory distress and/or 
pertussis.  Dr. Modlin testified in his deposition, “all 
pediatricians who care for acutely ill children, regardless of 
whether they are [emergency department] physicians or pediatric 
 
11
[infectious disease] physicians or general pediatricians should 
appreciate how pertussis can present in an infant.”3 
That uncontradicted testimony demonstrated that the 
standard of care, as it pertains to the medical procedure at 
issue, is the same for a physician with specialties in 
pediatrics and pediatric infectious diseases as it is for a 
physician with a specialty in pediatric emergency medicine.  
Thus, we hold that Dr. Modlin met the “knowledge” requirement of 
Code §  8.01-581.20.  Lloyd, 275 Va. at 109-10, 654 S.E.2d at 
569-70; Sami, 260 Va. at 284, 535 S.E.2d at 174. 
We now move to the question whether Dr. Modlin satisfied 
the “active clinical practice” requirement.  To qualify as an 
expert, Dr. Modlin needed an “ ‘active clinical practice in 
either [Dr. Qureshi’s] specialty or a related field of medicine 
within one year of the date of the alleged act or omission 
forming the basis of [the] action.’ ”  Sami, 260 Va. at 283, 535 
S.E.2d at 174 (quoting Code §  8.01-581.20). 
                     
3 Although Dr. Modlin never stated this opinion to a 
reasonable degree of medical probability, the defendants did not 
contemporaneously, or at any other time, object to this 
testimony.  Therefore, the testimony was properly before the 
circuit court to consider and may be relied upon by this Court 
on appeal.  See Bitar v. Rahman, 272 Va. 130, 141, 630 S.E.2d 
319, 325 (2006) (medical expert testimony admitted without a 
timely objection was properly considered by the jury 
notwithstanding the fact it was not stated within a reasonable 
degree of medical probability). 
 
12
In Sami, this Court addressed the application of the phrase 
“related field of medicine” contained in Code §  8.01-581.20.  
There, we stated that “[t]he purpose of the requirement in 
§  8.01-581.20 that an expert have an active practice in the 
defendant's specialty or a related field of medicine is to 
prevent testimony by an individual who has not recently engaged 
in the actual performance of the procedures at issue in a case.”  
260 Va. at 285, 535 S.E.2d at 175.  We therefore concluded that 
“in applying the ‘related field of medicine’ test for the 
purposes of §  8.01-581.20, it is sufficient if in the expert 
witness’ clinical practice the expert performs the procedure at 
issue and the standard of care for performing the procedure is 
the same.”  Id. 
It should be clear from our discussion concerning the 
“knowledge” requirement that the standard of care for the 
medical procedure at issue was the same with regard to Dr. 
Modlin’s specialties and Dr. Qureshi’s specialty.  Thus, the 
only remaining question is whether Dr. Modlin actually performed 
the procedure at issue in his clinical practice within one year 
of the date of the alleged negligent act or omission. 
With regard to the only relevant medical procedure at issue 
in this case, i.e., whether infant Jackson should have been 
admitted to inpatient hospital care when he presented at the 
emergency room showing signs of respiratory distress and/or 
 
13
pertussis, the record is clear that Dr. Modlin directly treated 
patients who presented with respiratory distress or pertussis 
within one year of the date of the alleged omission in this 
case.  Although Dr. Modlin admitted that he had not treated a 
patient presenting with pertussis in an emergency room during 
the relevant time frame, he testified that he had treated such 
patients in the urgent care clinic.  According to Dr. Modlin’s 
uncontradicted testimony, the urgent care clinic where he saw 
those patients and an emergency room are “very similar” clinical 
settings.  Thus, we conclude that Dr. Modlin met the “active 
clinical practice” requirement with regard to the relevant 
medical procedure at issue in this case.  Lloyd, 275 Va. at 109-
10, 654 S.E.2d at 569-70; Sami, 260 Va. at 284, 535 S.E.2d at 
174.   
The defendants, however, argue that the 25 to 30 percent of 
Dr. Modlin’s time spent in direct patient care was insufficient 
to establish that he had an “active” clinical practice with 
regard to the relevant medical procedure at issue.  We find this 
argument unpersuasive.  The provisions of Code §  8.01-581.20 do 
not set a minimum threshold amount of time a physician must 
spend in clinical practice to establish that such physician 
maintains an “active clinical practice,” and this Court is not 
free to impose one.  The statute states simply that the 
proffered expert must have an “active clinical practice” in the 
 
14
defendant’s specialty or a related field of medicine “within one 
year” of the alleged negligent act or omission.  Code §  8.01-
581.20.  
The record clearly demonstrates that, within the relevant 
one-year time frame, Dr. Modlin was engaged in an ongoing 
clinical practice and treated patients presenting with pertussis 
on more than a sporadic basis.  In contrast, we held in Hinkley 
v. Koehler, 269 Va. 82, 606 S.E.2d 803 (2005), that a teaching 
and consulting physician did not satisfy the “active clinical 
practice” requirement because he did not provide any direct 
patient care.  Id. at 90, 606 S.E.2d at 807.  Certainly, there 
may be instances when the expert’s clinical practice with regard 
to the medical procedure at issue is so de minimis that the 
witness would not meet the “active clinical practice” 
requirement.  However, in the case at bar, Dr. Modlin’s direct 
involvement in the treatment and care of patients presenting 
with respiratory distress or pertussis was not de minimis.  In 
this case, the purpose of the “active clinical practice” 
requirement, i.e., to prevent testimony by a physician who has 
not recently engaged in the actual performance of the medical 
procedure at issue, was clearly satisfied.  Thus, we hold that 
Dr. Modlin met the “active clinical practice” requirement of 
Code §  8.01-581.20. 
 
15
 
16
CONCLUSION 
 
Because it appears clearly from the record that Dr. Modlin 
met the “knowledge” requirement and the “active clinical 
practice” requirement of Code §  8.01-581.20, we conclude that 
the circuit court abused its discretion in holding otherwise.  
See Perdieu, 264 Va. at 418, 568 S.E.2d at 709.  Thus, we will 
reverse the judgment of the circuit court and remand for further 
proceedings. 
Reversed and remanded.