Title: Doherty v. Aleck
Citation: N/A
Docket Number: 060959
State: Virginia
Issuer: Virginia Supreme Court
Date: March 2, 2007

Present: Hassell, C.J., Lacy, Keenan, Koontz, Lemons, Agee, JJ., 
and Carrico, S.J.  
 
 
JOHN R. DOHERTY 
 
 
 
OPINION BY 
v.  Record No. 060959             SENIOR JUSTICE HARRY L. CARRICO 
 
 
 
March 2, 2007 
DEBRA J. ALECK, D.P.M., ET AL. 
 
FROM THE CIRCUIT COURT OF THE CITY OF PORTSMOUTH 
James A. Cales, Jr., Judge 
 
 
BACKGROUND 
 
In this medical malpractice case, the plaintiff, John R. 
Doherty, filed a motion for judgment against the defendants, 
Debra J. Aleck, D.P.M., and Podiatry, Ltd., a limited liability 
company wholly owned by Dr. Aleck.  In his motion for judgment, 
Doherty alleged that Dr. Aleck was negligent, inter alia, in 
failing to “refrain from contraindicated surgeries,” resulting 
in the amputation of the great toe on Doherty’s left foot. 
 
A jury returned a verdict in favor of Doherty in the amount 
of $850,000.00.  The defendants moved to set aside the verdict 
on the grounds Doherty’s medical expert, Dr. Noel P. Patel, had 
failed to testify to a reasonable degree of medical probability 
that Dr. Aleck breached the standard of care and that the 
alleged breach proximately caused Doherty’s injuries.  The trial 
court granted the motion, set the verdict aside, and entered 
final judgment in favor of the defendants.  We awarded Doherty 
this appeal. 
 
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STANDARD OF REVIEW 
 
In determining whether the verdict was properly set aside, 
we are guided by a well-settled standard of review.  Under Code 
§ 8.01-680, a trial court is empowered to set aside a verdict in 
a civil action on the ground it is “plainly wrong or without 
evidence to support it.”  However, as we explained in Lane v. 
Scott, 220 Va. 578, 260 S.E.2d 238 (1979):  
“[This power] can only be exercised where the verdict is 
plainly wrong or without credible evidence to support it.  
If there is a conflict in the testimony on a material 
point, or if reasonable [persons] may differ in their 
conclusions of fact to be drawn from the evidence, or if 
the conclusion is dependent on the weight to be given the 
testimony, the trial judge cannot substitute his conclusion 
for that of the jury merely because he would have voted for 
a different verdict if he had been on the jury.” 
 
Id. at 581, 260 S.E.2d at 240 (quoting Commonwealth v. McNeely, 
204 Va. 218, 222, 129 S.E.2d 687, 689-90 (1963)).   Further, “in 
considering the evidence, we give the recipient of the verdict 
the benefit of all substantial conflicts in the evidence and all 
reasonable inferences that may be drawn from the evidence.”  
Shalimar Dev., Inc. v. Federal Deposit Ins. Corp., 257 Va. 565, 
570, 515 S.E.2d 120, 123 (1999). 
THE FACTS 
 
The record shows that Doherty came under Dr. Aleck’s care 
in April of 2000 for a callous on the side of the great toe on 
his left foot.  At the time, Doherty was 74 years of age and 
suffering from diabetes and diabetic neuropathy with a history 
 
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of quintuple bypass surgery and the installation of a pacemaker 
one year earlier, as well as colon cancer and prostate cancer 
several years earlier.  In her 11 years of practice, Dr. Aleck 
had seen only two other patients who had undergone quintuple 
bypass surgery. 
 
Dr. Aleck began a course of treatment of Doherty’s callous, 
which included periodically shaving the callous and having the 
plaintiff wear a shoe that, he said, did not relieve the pain in 
his toe and got his “back out of whack.”  The shaving process 
continued for about ten months to the point where the process 
caused the callous to bleed and create a hole in the callous. 
 
By February of 2001, Doherty had developed a neuropathic 
ulcer in the same area as the callous, and his toe became red 
and swollen.  He made an appointment with Dr. Aleck, who noticed 
there was a “brewing infection underneath the skin.”  She “cut 
it, drain[ed] it, cultured it,” and put Doherty “on an 
antibiotic right away.” 
 
Nine months later, x-rays revealed a bone spur on Doherty’s 
left great toe “that was causing it . . . not to heal.”  On 
December 5, 2001, Dr. Aleck performed surgery in her office and 
removed the bone spur, and it is this surgery that is the 
subject of the present controversy.  Doherty returned home the 
same day with his foot completely bandaged. 
 
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On a follow-up visit five days later, Dr. Aleck removed the 
bandage, examined Doherty’s toe, and indicated everything was 
“fine.”  Two days later, Doherty’s wife called Dr. Aleck’s 
office because Doherty was in such pain that he was crying and 
his toe was hot and red.  Mrs. Doherty was only able to reach 
Dr. Aleck’s assistant, who told her to increase the pain 
medication, which she did.  In a second conversation the same 
day, the assistant told Mrs. Doherty that “they had done . . . 
extensive surgery on the foot.” 
 
Early on the morning of December 12, Mrs. Doherty called 
Dr. Aleck’s office again, this time in tears, because her 
husband was “hurting so bad” and she “could smell something but 
[she] didn’t know what it was.”  She asked to speak to the 
doctor, but was only allowed to talk to the assistant.  About 
six o’clock that evening, Dr. Aleck called Mrs. Doherty, who 
told the doctor what she had reported to the assistant earlier 
in the day.  Dr. Aleck told Mrs. Doherty to “bring [Doherty] in 
first thing in the morning.”  Mrs. Doherty asked where Dr. Aleck 
was, and when she was told the doctor was in the office, Mrs. 
Doherty said she was “bringing him tonight.”  Mrs. Doherty 
borrowed a wheelchair from a neighbor, put her husband in a car, 
and drove him to Dr. Aleck’s office. 
 
Dr. Aleck examined Doherty’s toe and found it malodorous, 
blackish in color, and with hemorrhagic drainage.  “The minute 
 
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[Dr. Aleck] saw [the toe],” she knew it “was a serious 
condition.”  As a podiatrist, she could only co-admit patients 
to a hospital, and she had to call several other doctors before 
she could arrange for Doherty’s admission.  Mrs. Doherty and 
other family members who had come to Dr. Aleck’s office took 
Doherty to the emergency room at Maryview Hospital.  Doherty was 
admitted to the hospital, and the next morning was examined by 
Dr. Elias J. Arbid, a vascular surgeon, who found Doherty  
suffering from “gangrene with a necrotizing infection” with “no 
way to salvage the toe.”  Dr. Arbid then amputated the toe. 
ANALYSIS 
 
On appeal, the defendants argue that the trial court was 
correct in setting aside the jury verdict because, as they 
argued in their motion to set aside the verdict, Doherty’s 
expert witness, Dr. Patel, did not testify to a reasonable 
degree of medical probability that Dr. Aleck breached the 
standard of care and that the alleged breach proximately caused 
Doherty’s injuries.  As Doherty points out, we have held that 
this argument is properly considered a challenge to the 
admissibility of the evidence, not a challenge to the 
sufficiency of the evidence.  Bitar v. Rahman, 272 Va. 130, 139, 
630 S.E.2d 319, 324 (2006).  Such a challenge must be raised 
when the evidence is presented and, as Bitar explains, comes too 
late “if the objecting party remains silent during its 
 
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presentation and brings the matter to the court’s attention by a 
motion to strike made after the opposing party has rested."  Id. 
In this case, the defendants did not object to the admission of 
Dr. Patel's testimony and, thus, the defendants' argument 
challenging the adequacy of Patel's testimony on the ground it 
was not to a reasonable degree of medical probability was not 
timely made.  Therefore, the trial court should not have 
considered this argument in deciding whether there was 
sufficient evidence to sustain the jury verdict and we will not 
consider it here.* 
 
The question in this case is not whether Dr. Aleck was 
negligent in the way she performed the spur-removal surgery on 
Doherty’s toe on December 5, 2001, but whether she was negligent 
in performing the surgery at all.  Our consideration of the 
issue of breach of the standard of care, therefore, will focus 
upon whether, as Doherty’s motion for judgment charged, the 
surgery was “contraindicated.” 
                     
* The defendants say we should not consider Doherty's argument 
concerning their failure to make a contemporaneous objection 
because Doherty's petition for appeal contained no assignment of 
error relating to that failure.  However, assignments of error 
are supposed to "list the specific errors in the rulings below 
upon which the appellant intends to rely," Rule 5:17(c), meaning 
errors of a court in a given case, not errors of a party in the 
handling of the case.  Furthermore, Doherty assigned error to 
the trial court's action in setting aside the verdict, and the 
defendants' failure to make a contemporaneous objection relates 
to that assignment because the failure to object directly 
 
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BREACH 
 
Dr. Patel, Doherty’s medical expert, testified that, given 
Doherty’s medical history, Doherty was “a poor candidate” for 
the surgery Dr. Aleck performed on December 5, 2001, and that 
the surgery “was not medically necessary at the time.”  Dr. 
Patel said that “[t]his is not an emergency procedure, this is 
more elective”; Doherty was more at risk of infection, gangrene, 
and amputation than one not suffering from similar conditions; 
and “the standard of care . . . with respect to doing surgery” 
would require one to “be very reserved and conservative and 
certainly not trying . . . to complicate matters more.” 
 
Dr. Patel also stated that “[a]fter reviewing the records 
of Dr. Aleck and the other consultants,” it was his opinion “Mr. 
Doherty was a poor choice for this elective procedure” and he 
“could have been treated conservatively.”  There was “a good 
chance,” Dr. Patel said, “that Mr. Doherty probably would have 
healed eventually with the conservative care,” and when asked on 
cross-examination “[h]ow much longer would [he] have gone on 
. . . with a patient like Mr. Doherty,” Dr. Patel replied, “[a]s 
long as it takes to keep that patient ambulatory, to keep that 
toe alive.” 
                                                                  
affects the quality of the evidence that must be evaluated in 
determining whether the verdict was property set aside. 
 
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Dr. Patel was also asked on cross-examination whether he 
understood “there may be a difference between what [he] would do 
individually and what the standard of care in the abstract would 
require.”  The doctor replied, “I think it’s prudent for the 
physician to make that decision from the standpoint of what a 
normal practicing physician would do under those circumstances, 
and my personal opinion is that [Dr. Aleck] did not do what a 
normal practicing physician would do under those circumstances.  
So therefore, she did breach the standard of care.” 
 
When asked on cross-examination whether it “would be fair 
to say” that “just because someone’s a poor candidate doesn’t 
mean it’s a breach of the standard of care for a doctor to 
address the problem surgically,” Dr. Patel replied, “there’s 
something called common sense.  I think as a physician you have 
to make that decision for the patient.  You have to protect the 
patient’s best interest.”  When pressed with the same question, 
the doctor stated:  “The standard of care, in my opinion, would 
be to breach from the norm, and as far as I’m concerned, this is 
a breach from the norm.”  And, although Dr. Patel agreed while 
on cross-examination that “whether to do surgery” was a matter 
of “[p]rofessional judgment,” he stated on redirect that Dr. 
Aleck’s surgery on Doherty “certainly was poor judgment.” 
 
As noted previously, the question in this case is not 
whether Dr. Aleck was negligent in the way she performed the 
 
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spur-removal surgery on December 5, 2001, but whether she was 
negligent in performing the surgery at all.  The defendants were 
quite successful in getting Dr. Patel to agree there was nothing 
negligent about the way Dr. Aleck performed the surgery, but, 
again, the defendants have missed the point.  We are of opinion 
that Dr. Patel’s testimony as supplemented by the medical 
records was clearly sufficient to make a jury issue of whether 
Dr. Aleck was negligent in performing the surgery at all. 
CAUSATION 
 
“ ‘The proximate cause of an event is that act or omission 
which, in natural and continuous sequence, unbroken by an 
efficient intervening cause, produces the event, and without 
which that event would not have occurred.’ ”  Jenkins v. Payne, 
251 Va. 122, 128, 465 S.E.2d 795, 799 (1996) (quoting Beale v. 
Jones, 210 Va. 519, 522, 171 S.E.2d 851, 853 (1970)).  “There 
may be more than one proximate cause of an event.”  Jenkins, 251 
Va. at 128, 465 S.E.2d at 799.  Thus, the question is whether 
the surgery Dr. Aleck performed on Doherty on December 5, 2001, 
was a proximate cause of the amputation of his toe. 
 
In addition to the evidence concerning Doherty’s age and 
the pre-surgery debilitating condition of his health, the record 
shows a continuous sequence of events commencing with the 
surgery on December 5, 2001, followed only eight days later by 
the amputation of his toe on December 13.  Dr. Patel testified 
 
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that Dr. Aleck had used a tourniquet on Doherty’s toe during the 
surgery, which he said was an accepted procedure, but “when you 
release that tourniquet, you get a flow of blood especially into 
that area,” and “that can lead to a more complicated condition 
where he has ischemia”; “[i]schemia is a lack of blood flow to 
the area,” and the “number one cause of [gangrene developing in 
Mr. Doherty’s situation] is ischemia, lack of blood flow to the 
area.”  And from his “reading of the notes,” Dr. Patel concluded  
“it was gangrene” that was “the reason for the amputation.” 
 
The defendants assert, however, that Dr. Patel “undermined 
his already weak testimony regarding proximate cause when he 
admitted that Mr. Doherty may have undergone an amputation even 
absent Dr. Aleck’s surgery.”  The defendants point out that Dr. 
Patel said there was “a possibility [Doherty] would probably go 
on to amputation” and that “diabetic patients can go on to 
develop gangrene even if a podiatrist does everything right.” 
 
We disagree with the defendants’ characterization of the 
strength of Dr. Patel’s testimony.  But, if Doherty’s proof of 
causation was lacking in some respect, the deficiency was 
removed by the testimony of two of the defendants’ own 
witnesses.  The defendants’ medical expert, Dr. Laurence Rubin, 
testified on direct examination that Doherty had a post-
operative infection, rather than ischemia, and that “[m]other 
nature” caused the infection.  However, when asked on cross-
 
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examination “[d]oes mother nature cut off circulation like a 
tourniquet . . . [p]ostoperatively,” his answer was, 
“[p]ostoperatively, no.”  And, Dr. Arbid, who amputated 
Doherty’s toe and who testified for the defendants, supplied the 
clincher.  He was asked “[w]hether anything [Dr. Aleck] did 
caused Mr. Doherty to need a great toe amputation.”  The doctor 
replied, “I’d like for you to clarify that, because clearly that 
occurred as a result of a previous procedure she had performed.”  
(Emphasis added.) 
 
Finally, with regard to Dr. Patel’s testimony that there 
was “a possibility [Doherty] would probably go on to amputation” 
(emphasis added), the law in this area deals in probabilities 
and not possibilities.  Fairfax Hosp. System, Inc. v. Curtis, 
249 Va. 531, 535, 457 S.E.2d 66, 69 (1995).  Furthermore, anyone 
who reads the record in this case should come away convinced 
that, with a patient in the stressful situation in which Doherty 
found himself, it was probable that, but for Dr. Aleck’s 
surgery, Doherty would not have suffered the amputation of his 
toe.  We are of opinion, therefore, that the evidence was 
clearly sufficient to make a jury issue of whether the surgery 
Dr. Aleck performed on Doherty was a proximate cause of the 
amputation of his toe. 
 
Accordingly, we hold that the jury’s verdict was supported 
by credible evidence, and we will reverse the judgment of the 
 
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trial court, reinstate the jury verdict, and enter final 
judgment in favor of Doherty. 
Reversed and final judgment.