Title: Elizabeth Mitchell, et al., Appellants vs. Milton Kardesch, M.D., Respondent.
Citation: N/A
Docket Number: SC90370
State: Missouri
Issuer: Missouri Supreme Court
Date: June 15, 2010

SUPREME COURT OF MISSOURI 
en banc 
 
ELIZABETH MITCHELL, et al., 
 
) 
 
 
 
 
 
 
 
) 
 
Appellants,  
 
 
 
) 
 
 
 
 
 
 
 
) 
vs. 
 
 
 
 
 
 
) 
No. SC90370 
 
 
 
 
 
 
 
) 
MILTON KARDESCH, M.D.,  
 
) 
 
 
 
 
 
 
 
) 
 
Respondent.  
 
 
 
) 
 
Appeal from the Circuit Court of St. Louis County 
The Honorable Steven H. Goldman, Judge 
 
Opinion issued June 15, 2010 
 
Elizabeth Mitchell, along with her two minor children,1 sued Dr. Milton Kardesch 
for medical malpractice, claiming that Dr. Kardesch deviated from the standard of care 
(1) in not appropriately evaluating, diagnosing and treating her husband, Ruben Mitchell, 
or referring him for treatment and (2) in not acting within the standard of care upon 
recording abnormalities in Mr. Mitchell’s thallium stress test.  Because much of the case 
would turn on whether the jury believed her or Dr. Kardesch’s recitation of events, Mrs. 
Mitchell requested permission to ask Dr. Kardesch about his admission in his deposition 
that he had given a false answer in his sworn response to an interrogatory in this case
                                             
 
1 For purposes of clarity, all plaintiffs sometimes are referred to collectively as “Mrs. 
Mitchell.” 
about whether his license to practice medicine ever had been suspended, and to utilize the 
interrogatory answer and deposition if he denied what he had stated therein. 
The trial court believed that the issue of Dr. Kardesch’s inaccurate answer was not 
relevant or material to Mrs. Mitchell’s claim and prohibited counsel from asking Dr. 
Kardesch about it or impeaching him with the interrogatory answer or deposition.2  The 
jury found in favor of Dr. Kardesch on all counts.  Mrs. Mitchell appeals.  This Court 
reverses and remands for a new trial. 
“It has long been the rule in Missouri that on cross-examination a witness may be 
asked any questions which tend to test his accuracy, veracity or credibility ….”  Sandy 
Ford Ranch, Inc. v. Dill, 449 S.W.2d 1, 6 (Mo. 1970).  To the extent State v. Wolfe, 13 
S.W.3d 248, 258 (Mo. banc 2000), and its progeny hold otherwise, they misinterpreted 
this Court’s prior cases and should not be followed. 
While the right to cross-examine a witness on the stand is subject to the trial 
court’s discretion to weigh the probative value of the evidence against its prejudicial 
effect, State v. Freeman, 269 S.W.3d 422, 427 (Mo. banc 2008), here the plaintiffs 
offered to limit their questions so that the jury would not be aware of the reasons for the 
suspension.  The probative value of showing that Dr. Kardesch allegedly was willing to 
give a false answer to this interrogatory to protect himself from embarrassment and the 
credibility of his deposition attempt to explain why he had done so were relevant to the
                                             
 
2 The trial court did permit plaintiffs’ counsel to ask Dr. Kardesch whether his 
interrogatory answers as a whole were truthful but forbid counsel from following up this 
answer. 
jury’s determination of whose account of events was most credible: his or Mrs. 
Mitchell’s. 
This Court also finds that the trial court erred in ruling that it would not permit 
plaintiffs to use Dr. Kardesch’s deposition and interrogatory answers as extrinsic 
evidence should he deny their content at trial.  The Court here formalizes the ad hoc 
exceptions to the bar on extrinsic evidence that were recognized for prior false 
accusations in cases such as State v. Black, 151 S.W.3d 49, 55 (Mo. banc 2004), and for 
evidence that bore strongly on plaintiff’s essential soundness as a witness in cases such as 
Roberts v. Emerson Elect. Mfg. Co, 362 S.W.2d 579, 584 (Mo. 1962): where the 
relevance and probativeness of such evidence on the issue of the party’s character for 
truth and veracity is so great that it would deprive the jury of evidence highly relevant to 
its resolution of material issues, extrinsic evidence is admissible, subject to the trial 
court’s discretion to limit or exclude it so as to avoid undue prejudice.  Here, the 
relevance of Dr. Kardesch’s willingness to swear falsely in this very case is so relevant 
and probative on the central issue of whose version of the facts to believe that the trial 
court abused its discretion in entirely excluding it. 
I. 
FACTUAL AND PROCEDURAL BACKGROUND 
A. 
Initial Response of Dr. Kardesch to Mrs. Mitchell’s Call 
On October 11, 2001, Ruben Mitchell awoke in the middle of the night clutching 
his chest after having a nightmare about death.  After Mr. Mitchell left for work the 
following morning, Mr. Mitchell’s wife, Elizabeth Mitchell, called the office of Dr. 
Milton Kardesch, who was Mr. Mitchell’s general internist.   
 
3
Speaking with Dr. Kardesch’s medical assistant, Mrs. Mitchell relayed the 
previous night’s episode.  In her note documenting her conversation with Mrs. Mitchell, 
the medical assistant wrote: “October 11, 2001, Ruben Mitchell, diet; eats anything, 
night; sleep, nightmare, grabs chest, sleeps after work, never used to nap.”  The medical 
assistant did testify she made a note of the Mitchells’ telephone number and drew a line 
on the message slip, later explaining at trial, “That line means that I went back to talk to 
Dr. Kardesch about this phone call.”  The parties dispute what occurred next.  Because 
Dr. Kardesch raises a sufficiency of the evidence issue, the evidence is set out in detail. 
Dr. Kardesch’s medical assistant testified she had no specific recollection of Mrs. 
Mitchell’s call.  Neither she nor Mrs. Mitchell could recall if Mrs. Mitchell also had 
mentioned chest pain, but the medical assistant said that even had Mrs. Mitchell so 
indicated, her practice was not to write down such complaints.  Instead, she said it was 
her general practice to “speak to the patient, get a phone number, go back and talk to Dr. 
Kardesch, and I would write down whatever Dr. Kardesch would tell me the patient 
should do.”  
Reviewing her own notes documenting both her call with Mrs. Mitchell and her 
related conversation with Dr. Kardesch, the medical assistant indicated the doctor 
believed Mr. Mitchell’s symptoms might have been related to one of Mr. Mitchell’s heart 
medications.  This was corroborated by Dr. Kardesch’s testimony that he told his 
assistant that a side effect of a beta-blocker taken by Mr. Mitchell included “bad dreams 
and nightmares.”  The assistant’s notes also stated Dr. Kardesch’s diagnosis was 
arteriosclerotic heart disease and to “rule out angina.”  The assistant said she did not 
 
4
recall Dr. Kardesch directly speaking on the telephone with Mrs. Mitchell.  
Dr. Kardesch later testified that he remembered Mrs. Mitchell’s telephone call 
regarding her husband because of the unique nature of “a phone call that involved 
grabbing at the chest and having a nightmare.”  Dr. Kardesch confirmed both that he did 
not speak directly with Mrs. Mitchell on the telephone on October 11, 2001, and that his 
diagnoses had been arteriosclerosis and to “[r]ule out angina.”  He further stated that at 
the time of the call he believed Mr. Mitchell’s symptoms simply pointed to a nightmare.  
Regardless, not wanting “to waste time” and feeling it was important that a patient with 
Mr. Mitchell’s “past history” seek immediate medical care, Dr. Kardesch testified that he 
instructed his assistant to tell Ms. Mitchell “to get Mr. Mitchell over to the emergency 
room.”  
Dr. Kardesch’s assistant conceded at trial that she had no recollection of telling 
Mrs. Mitchell to take her husband to the emergency room, and her note of the 
conversation does not contain that advice.  She said she nonetheless thought she told Mrs. 
Mitchell to go to the emergency room because, “It was automatic that if a patient was 
having chest pain, they needed to go to the emergency room, and it was never written.  It 
was just verbal.”   
Mrs. Mitchell flatly contradicted the medical assistant’s assumption that she must 
have said to take Mr. Mitchell to the emergency room.  Mrs. Mitchell said that she never 
was instructed to take her husband to the emergency room: “That did not happen.  If they 
would have told me to take him anywhere, I would have taken him immediately.”  Mrs. 
Mitchell further testified that as her husband was a journeyman plumber with 28 years 
 
5
seniority, he was allowed to leave work for medical purposes and that he would have 
done so “immediately” if Dr. Kardesch’s office had so directed.  No one disputes that Mr. 
Mitchell did not go to the emergency room on October 11, 2001.  
Dr. Donald Singer, a cardiologist and professor of medicine at the University of 
Illinois in Chicago, testified that Dr. Kardesch deviated from the standard of care in his 
management of Mr. Mitchell’s medical treatment.  Specifically, Dr. Singer testified that 
Dr. Kardesch should have spoken directly with Mrs. Mitchell to better understand Mr. 
Mitchell’s symptoms, and, importantly to the facts of this case, Dr. Kardesch should have 
“shipped the patient off to the emergency room.”  Further, Dr. Singer testified that Dr. 
Kardesch needed to “get on this patient” and immediately order a series of tests, some of 
which were possible to complete within Dr. Kardesch’s office.  To a reasonable degree of 
medical certainty, Dr. Singer testified, Dr. Kardesch breached the standard of care in not 
following these procedures.   
B. 
Delay in Ordering Stress Test 
It is also undisputed that Dr. Kardesch ordered a thallium stress test at St. Joseph’s 
Hospital, but it was not performed until October 22, 2001, a full 11 days after he decided 
that Mr. Mitchell needed to have a stress test.  The reason for the delay is in dispute. 
According to Dr. Kardesch, after instructing his medical assistant to direct Mrs. 
Mitchell to take her husband to the emergency room, Mrs. Mitchell made a follow-up call 
to the office stating that her husband “was at work feeling fine, that he had no further 
chest problems and no chest pain.”  Although this lessened Dr. Kardesch’s suspicions of 
coronary artery disease, he testified that he next asked his assistant “to schedule a stress 
 
6
test” and thought the test “would just be done the next day ….”  He further stated that it 
was “[p]retty rare” to have an occasion when St. Joseph’s was not able to perform a stress 
test “within a day or two” if fitting with the patient’s schedule and, if it could not, 
arrangements could be made at another hospital.  According to Dr. Kardesch, “The plan 
was” to “check with Mr. Mitchell’s work schedule” and have Mrs. Mitchell let Dr. 
Kardesch’s office know “a good date for Mr. Mitchell to have this stress test.”  
Dr. Kardesch’s assistant testified that she could not recollect the reason why the 
stress test was not scheduled until October 22, 2001, but in her deposition she stated that 
was “the first time we could get it scheduled ….”  She also agreed, “Normal procedure to 
do any [thallium stress] test is the next day.  You always schedule it for the next day.  If it 
isn’t scheduled, then there is a reason because of the patient’s schedule.” 
The fact remains that the test was not scheduled for 11 days.  Mrs. Mitchell 
testified this was because Dr. Kardesch’s assistant simply told her “that Dr. Kardesch was 
going to order a stress test” and that the assistant would “get back” to Mrs. Mitchell with 
the appointment.  It was not until about a week later that the assistant called and told her 
that the stress test had been scheduled for October 22.  Mrs. Mitchell said the delay was 
not because of her husband’s schedule, that she would have taken him to receive the 
stress test “[w]henever they wanted me to.”  She said Mr. Mitchell’s convenience “was 
never an issue” and the delay “was not for [Mr. Mitchell’s] convenience.  He could have 
gone at any time.  Must have been for their convenience.” 
Mrs. Mitchell’s expert, Dr. Singer, testified that had Mr. Mitchell received a stress 
test October 11, 2001, there would have been signs of myocardial ischemia that were not 
 
7
later found due to the delay in testing.  He said Dr. Kardesch “failed to appropriately 
evaluate, diagnose and treat Mr. Mitchell … on or after October 11, 2001.”  If the testing 
had been done earlier, Dr. Singer testified to a reasonable degree of medical certainty, 
Mr. Mitchell “would not have developed a heart attack, and he would not have this need 
to have an emergency catheterization, and he would not have had the [complications] that 
particularly resulted in the … infarct that killed him.” 
Dr. Patricia Cole testified that the delay did not affect the stress test results and 
that Dr. Kardesch did not deviate from the standard of care.  She explained, to a 
reasonable degree of medical certainty, that if Mr. Mitchell showed symptoms of 
myocardial ischemia October 11, 2001, those same signs also would have been present 
during the October 22 stress test. 
C. 
Stress Test Results 
 
Once the thallium stress test was completed October 22, 2001, Dr. Kardesch read 
the results and informed the Mitchells that Mr. Mitchell’s test was normal and immediate 
treatment was not required.  Further, he reported that Mr. Mitchell’s “ability to perform 
on the treadmill” was above average, that he had not complained of chest pain during the 
stress test, and that the results of the test were “negative … by EKG criteria.”  The test, 
however, had to be stopped because Mr. Mitchell became short of breath.  The 
cardiologist recorded that, at 38.7 percent, Mr. Mitchell had a “mildly depressed ejection 
fraction.”   Dr. Kardesch explained the term “ejection fraction”:  
When the heart fills up, and is beating to get the blood out, it never really 
empties completely.  The normal amount for emptying is 50 to 60 percent.  
That’s called an ejection fraction. 
 
8
 
 
 
Dr. Kardesch did not tell the Mitchells about the depressed ejection fraction as he 
felt the reading just “was wrong.”  Dr. Kardesch explained, “It was a good test otherwise, 
and … the nuclear fraction is always much lower than the echocardiogram. …  I really 
didn’t believe that it was truly that low, and I was going to get an echocardiogram.   He 
continued, “And I figured, well, I was going to see him right away.”  Dr. Kardesch, 
however, did not order an echocardiogram, and he was mistaken that he had scheduled an 
appointment with Mr. Mitchell right away.  Mr. Mitchell had a heart attack three days 
later. 
 
Dr. Singer testified that Dr. Kardesch’s failure to send Mr. Mitchell to a specialist 
for further testing constituted a deviation from the standard of care.  If Dr. Kardesch “did 
his job right … he simply had to say, [‘]This is a potential problem.  We need to have it 
looked at at a higher and more specialized level….[’]”  At that point, if Dr. Kardesch had 
sent Mr. Mitchell to receive a catheterization, according to Dr. Singer, a specialist “would 
have been able to fix that vessel, and that would have prevented the occurrence of the 
heart attack that did [Mr. Mitchell] in three days later.” 
Dr. Cole testified that, to the contrary, it was not a deviation from the standard of 
care for Dr. Kardesch to not compare the results with the July 2000 catheterization test, in 
which the result was 50 percent.  Both readings, she stated, constituted “a mild 
depression” and, in light of the different technique used on the second occasion, that test 
did not per se represent a significant change from the July 2000 test.  As a result, Dr. 
Kardesch’s reading of the stress test complied with the standard of care.  
 
9
D. 
The Death and Subsequent Lawsuit 
On the morning of October 25, 2001, Mr. Mitchell began suffering chest tightness 
and sweating and drove himself to the emergency room at St. Joseph’s Health Center.  He 
was diagnosed with acute lateral myocardial infarction and underwent an immediate 
cardiac catheterization followed by angioplasty and the insertion of a stent.  Due to 
complications arising from the catheterization procedure, and the decision to take Mr. 
Mitchell off blood thinners, a blood clot developed around Mr. Mitchell’s stent, which 
triggered another cardiac event.  Mr. Mitchell died October 26, 2001, from complications 
arising from myocardial infarction and arteriosclerosis.  
Mrs. Mitchell and her and her husband’s two minor children filed a wrongful 
death action against Dr. Kardesch on the theories that Dr. Kardesch deviated from the 
standard of care in: (1) not appropriately evaluating, diagnosing and treating Mr. Mitchell 
or referring him for treatment on or after October 11, 2001, and/or (2) not acting within 
the standard of care upon recording abnormalities in Mr. Mitchell’s stress test taken 
October 22, 2001.3
Much of the trial turned on whether the jury believed Dr. Kardesch or Mrs. 
Mitchell.  Because credibility was such a central issue, Mrs. Mitchell requested 
permission to ask Dr. Kardesch about a false answer that he gave in his sworn response to 
an interrogatory answer in this case.  The interrogatory asked him to “[s]tate whether any 
                                             
 
3 While there was not directly conflicting factual testimony as to Dr. Kardesch’s course 
of conduct upon reading the stress test results, the jury’s assessment of his credibility 
may have affected its belief of his explanation as to why he failed to send Mr. Mitchell to 
a cardiologist after getting the low ejection fraction reading on the stress test.  
 
10
professional license held by you has ever been suspended or revoked, or if renewal has 
ever been refused.”  He answered “No.”  In fact, his Missouri and his New York licenses 
to practice medicine both had been suspended due to a Missouri felony conviction 
unrelated to his medical abilities, as he later admitted in a deposition devoted solely to 
resolving this conflict between his interrogatory answer and the fact of his suspensions. 
Mrs. Mitchell did not contest the court’s ruling that the underlying reasons behind 
the suspension itself should be excluded because it was more prejudicial than probative.  
Mrs. Mitchell argued below and argues in this Court, however, that the fact that Dr. 
Kardesch gave a false answer under oath in this very case to hide an embarrassing fact 
was relevant to the central issue on which the case would turn – his credibility.  The trial 
court found the evidence collateral and prohibited plaintiffs from asking Dr. Kardesch 
about the suspension of his Missouri medical license, in particular, and from introducing 
either the false answer or Dr. Kardesch’s deposition testimony in which he admitted his 
answer was inaccurate and sought to justify it. The court permitted counsel to ask Dr. 
Kardesch only a single question: whether his interrogatory answers generally were 
truthful. Counsel was prohibited from showing that the doctor’s “yes” answer was not 
accurate.  
The jury found in favor of Dr. Kardesch on all counts.  Mrs. Mitchell appeals.  
After decision by the court of appeals, this Court granted transfer.  Mo. Const. art. V, § 
10.   
 
 
 
11
II. 
STANDARD OF REVIEW 
 
“The admissibility of evidence lies within the sound discretion of the trial court 
and will not be disturbed absent abuse of discretion.”  Nelson v. Waxman, 9 S.W.3d 601, 
603 (Mo. banc 2000).  This standard gives the trial court “broad leeway in choosing to 
admit evidence,” and its exercise of discretion will not be disturbed unless it “‘is clearly 
against the logic of the circumstances and is so unreasonable as to indicate a lack of 
careful consideration.’”  State v. Freeman, 269 S.W.3d 422, 426-27 (Mo. banc 2008), 
quoting, State v. Forrest, 183 S.W.3d 218, 223 (Mo. banc 2006).  In part, such broad 
leeway is granted to ensure the probative value of admitted evidence outweighs any 
unfair prejudice.  Freeman, 269 S.W.3d at 427, quoting, State v. Anderson, 76 S.W.3d 
275, 276 (Mo. banc 2002).  “For evidentiary error to cause reversal, prejudice must be 
demonstrated.”  State v. Reed, 282 S.W.3d 835, 837 (Mo. banc 2009).   
III. 
CROSS-EXAMINATION AND USE OF EXTRINSIC EVIDENCE TO 
SHOW PARTY’S CHARACTER FOR TRUTH AND VERACITY  
 
Dr. Kardesch argues that the trial court acted correctly in prohibiting plaintiffs 
from examining him about his sworn interrogatory answer that his medical license had 
not been suspended and in prohibiting use of his deposition or interrogatory answer as 
extrinsic evidence to show that this answer was untrue.  This Court disagrees. 
A. 
Forms of Impeachment 
To better understand the legal principles at issue, it is helpful to begin by 
comparing the categories and purposes of impeachment recognized in Missouri. 
“As a general proposition, the credibility of witnesses is always a relevant issue in 
 
12
a lawsuit.”  State v. Smith, 996 S.W.2d 518, 521 (Mo. App. 1999).  Impeachment 
provides a tool to test a witness’s perception, credibility, and truthfulness, which is 
essential because a jury is free to believe any, all, or none of a witness’s testimony.  State 
v. Hineman, 14 S.W.3d 924, 927 (Mo. banc 1999); Talley v. Richart, 185 S.W.2d 23, 
26 (Mo. 1945) (a party impeaches a witness to discredit the witness in the eyes of the 
fact-finder).  For this reason, as this Court noted in Sandy Ford Ranch, Inc. v. Dill: 
It has long been the rule in Missouri that on cross-examination a witness 
may be asked any questions which tend to test his accuracy, veracity or 
credibility or to shake his credit by injuring his character. He may be 
compelled to answer any such question, however irrelevant it may be to the 
facts in issue, and however disgraceful the answer may be to himself, 
except where the answer might expose him to a criminal charge.  
 
449 S.W.2d 1, 6 (Mo. 1970).  The most commonly recognized methods of impeaching a 
witness include: 
• admission of evidence showing the witness’s incapacity or problems in his or  
her ability to perceive or memory;  
• admission of evidence of prior convictions; 
• admission of evidence of the witness’s bias, interest or prejudice; 
• admission of prior inconsistent statements of the witness; 
• admission of evidence of the witness’s character for truthfulness and veracity.4 
Each method of impeachment is governed by its own specific procedures and rules 
regarding cross-examination and the admissibility of extrinsic evidence. These rules 
                                             
 
4 In addition, evidence creating or highlighting a contradiction, while directed to the 
accuracy of a witness’s testimony by supplying contradictory factual evidence, also 
inherently affects credibility by undermining confidence in the reliability of the victim’s 
 
13
developed under the common law in an attempt to permit admission of relevant evidence 
affecting credibility without causing undue prejudice to the other party or diverting the 
jury’s focus from relevant issues.  
B. 
Cross-Examination of a Witness on the Stand for Impeachment Is 
Permitted under All Impeachment Categories  
  
Cross-examination of a witness on the stand for the purpose of impeaching that 
witness through each of the methods just listed long has been permitted in Missouri, 
subject to the court’s discretion in limiting or, in rare instances, precluding such evidence 
entirely so as to avoid undue prejudice.  Freeman, 269 S.W.3d at 427.   This is true 
regardless of the method of impeachment being employed.  For instance, Lagud v. 
Kansas City Bd. of Police Com’rs, 136 S.W.3d 786, 793 (Mo. banc 2004), held it was 
error to prohibit counsel from cross-examining a witness about his drug use as it goes to a 
witness’s “very capacity and competence as a witness to perceive ….”5  Numerous cases 
also approve cross-examination about prior convictions, even though the prior 
convictions do not involve similar facts, because, when “a defendant chooses to testify, 
he places his credibility in issue and he may be impeached by prior criminal convictions.”  
State v. Carothers, 710 S.W.2d 370, 371 (Mo. App. 1986).  See also State v. Holden, 
278 S.W.3d 674, 681 (Mo. banc 2009); § 491.050, RSMo 2000. 
                                                                                                                                                 
 
testimony.  Waters v. Barbe, 812 S.W.2d 753, 757 (Mo. App. 1991). 
5 Lagud continued that therefore “[t]he intoxication of a witness as of the time the events 
took place that are the subject of the witness’s testimony is not a collateral issue but bears 
directly upon the ability of the witness to accurately describe those events”).  See also 
State v. Caston, 509 S.W.2d 39, 41 (Mo. 1974) (cross-examination about intoxication of 
witness at time of event bears directly on perception and is admissible); State v. Phillips, 
939 S.W.2d 502, 505 (Mo. App. 1997) (same). 
 
14
Missouri similarly permits cross-examination where the witness’s testimony at 
trial is inconsistent with a prior statement, but here the cases generally require the prior 
statement to be about a material issue.  State v. Black, 151 S.W.3d 49, 55 (Mo. banc 
2004), held that a “judge cannot preclude a defendant from impeaching a prosecution 
witness with prior inconsistent statements if the impeachment does not concern an 
immaterial or collateral matter.” But the cases broadly define materiality to include 
statements affecting credibility.  For example, Kearbey v. Wichita Se. Kan., 240 S.W.3d 
175, 187 (Mo. App. 2007), held that admission of prior inconsistent statements about 
marijuana use made by defendant in response to various medical questionnaires was 
admissible, noting that “the jury could infer that a person who is not consistently truthful 
in statements made to other persons might also be untruthful in his testimony on the 
witness stand.” 
And it is well-settled that “the interest or bias of a witness and his relation to or 
feeling toward a party are never irrelevant matters.”  State v. Johnson, 700 S.W.2d 815, 
817 (Mo. banc 1985), quoting, State v. Edwards, 637 S.W.2d 27 (Mo. banc 1982).  
Cross-examination about any issue, regardless of its materiality to the substantive issues 
at trial, is permissible if it shows the bias or interest of the witness because a witness’s 
bias or interest could affect the reliability of the witness’s testimony on any issue.  Id.  
Most relevant here, cross-examination also long has been permitted to impeach a 
witness on his or her character for truth and veracity.  This means of impeachment, 
however, must be directed only toward the ultimate issue of a witness’s credibility; thus, 
a witness may not be impeached by evidence that his or her “general moral character is 
 
15
bad”6 or that his or her “general reputation for morality” is bad.7  Therefore, this form of 
impeachment must be confined to the witness’s character for truthfulness and veracity.  
State v. Gregory, 822 S.W.2d 946, 949 (Mo. App. 1992).8  Traditionally, different 
limitations on such impeachment applied depending on whether the one whose character 
for truth and veracity being impeached was (1) the person on the stand or (2) someone 
else about whom the person on the stand was being questioned.   
When a person, regardless of whether a party, is being questioned on the witness 
stand, then long-standing Missouri law holds that the person may be asked about specific 
instances of his or her own conduct that speak to his or her own character for truth or 
veracity, even where the issue inquired about is not material to the substantive issues in 
the case. Accordingly, Sandy Ford Ranch, Inc., states that the trial court did not err in 
permitting cross-examination of a witness about allegedly objectionable matters, for: “It 
has long been the rule in Missouri that on cross-examination a witness may be asked any 
                                             
 
6 State v. Spencer, 472 S.W.2d 404, 405 (Mo. 1971) (reversible error to permit cross-
examination of whether the witness “had two illegitimate children before she married 
appellant”); see also Taylor v. State, 262 S.W.3d 231, 244-45 (Mo. banc 2008) (where 
this Court held that evidence of a witness’s racism and criminal history were not proper 
as it did not directly attest to the witness’s veracity). 
7 State v. Williams, 87 S.W.2d 175, 183-84 (Mo. 1935) (where an African-American 
woman accused of murder claimed self-defense, this Court expressly overruled cases 
allowing for impeachment by evidence of general morality and held “the trial court 
committed error in admitting testimony of the [defendant’s] bad general reputation for 
morality”). 
8 The reason for allowing evidence of a witness’s character for truth and veracity, while 
generally not allowing evidence of a bad general moral character, is that a witness’s 
character for truth and veracity does not put the witness’s overall character in issue, but 
rather only the witness’s credibility—the ultimate issue.  See State v. Harlow, 37 S.W.2d 
419, 421 (Mo. banc 1931).  
 
 
16
questions which tend to test his accuracy, veracity or credibility ….”  449 S.W.2d at 6.  
Accord, State v. Williams, 492 S.W.2d 1, 6 (Mo. App. 1973).  
This rule was applied in State v. Zahn, 823 S.W.2d 18, 22 (Mo. App. 1991), to 
permit the state to cross-examine the defendant about whether “he perjured himself 
during his dissolution case by denying under oath that he had ever had sexual intercourse 
with [a woman].”  After noting the point was not properly preserved, the court stated: 
Furthermore, it is within the trial court’s discretion to permit cross-
examination of a witness directed toward testing his or her credibility, 
however irrelevant such examination may be to the basic issues.”  State v. 
Jackson, 768 S.W.2d 614, 616 (Mo. App. 1989).  It is not error to allow 
cross-examination regarding specific instances of unconvicted conduct if 
relevant to impeach the veracity of the defendant.  
 
Id. (emphasis added). 
By contrast, if a witness is called to impeach the character of a different witness in 
the case for truth and veracity, then the witness on the stand initially may be asked only 
about the other person’s general reputation in the community for truth and veracity.  
Hayman v. Laclede Elec. Coop., Inc., 827 S.W.2d 200, 205 (Mo. banc 1992); State v. 
Trimble, 638 S.W.2d 726, 735 (Mo. banc 1982) (by taking the stand, a party places his 
or her reputation in issue and, therefore, the other party can offer evidence of his or her 
general reputation for truthfulness).  Only once the witness has testified to the other’s 
reputation may he or she be cross-examined in good faith about specific instances of 
conduct, and even then only as a means of testing the accuracy of the witness’s testimony 
about the other’s reputation for truthfulness by asking whether the person on the stand 
has “heard about” a particular matter.  State v. Brooks, 960 S.W.2d 479, 494 (Mo. banc 
 
17
1997); Leavell v. Leavell, 89 S.W.55, 57 (Mo. App. 1905). 
These well-settled rules were put into a state of some confusion 10 years ago in 
State v. Wolfe, 13 S.W.3d 248, 258 (Mo. banc 2000).  Wolfe involved the question of 
whether defense counsel could cross-examine an adult female witness, who claimed that 
defendant had kidnapped her, about a kidnapping story she admittedly had fabricated to 
police when she was 12 years old.  Defendant argued that the similarity of the accusation 
made it relevant and probative and that questions about it were admissible to impeach the 
witness’s character for truth and veracity.  And, in fact, under the cases just discussed, the 
law did so permit, except as limited by the trial court’s exercise of its discretion to avoid 
undue prejudice.  The trial court in Wolfe refused to allow any cross-examination on this 
issue, however.  This Court upheld the decision, stating:  
The impeaching testimony should be confined to the real and ultimate 
object of the inquiry, which is the reputation of the witness for truth and 
veracity.  In other words, specific acts of misconduct, without proof of bias 
or relevance, are collateral, with no probative value.  
  
13 S.W.3d 248, 258 (Mo. banc 2000) (citation omitted).  
Of course, as just noted, Wolfe was correct that reputation for truth and veracity is 
the “real and ultimate object of an inquiry” when one asks the person on the stand about 
someone else’s reputation.  That was the subject of the sole case cited by Wolfe for this 
proposition, State v. Williams, 87 S.W.2d 175, 182-83 (1935), in which six character 
witnesses were asked about the defendant’s reputation for truth and veracity.  Williams 
was not concerned with asking the witness on the stand about his or her own character for 
veracity, however, much less did it state that such questions must be limited to asking the 
 
18
witness about his or her own reputation for veracity or truthfulness.  Indeed, it would 
make little sense to ask a person on the stand about his or her own reputation – and the 
answer only could be hearsay in any event, for “reputation” by its nature is “the character 
imputed to a person by those acquainted with him,” not what a person thinks of himself.   
BLACK’S LAW DICTIONARY 1303 (6th ed. 1990). 
The effect of mixing these two standards was to eliminate the traditional method 
of impeachment of a witness on the stand by asking him or her about specific instances of 
conduct that bore on his or her character for truth and veracity.  Sandy Ford Ranch, 449 
S.W.2d at 6.  Wolfe accomplished this without any discussion, analysis or recognition 
that it was overruling decades of cases sub silentio.   For this reason, even the dissenting 
opinion, while noting that the majority’s statement was inconsistent with many prior 
cases, did not discuss that the error arose by conflating the two standards for admission of 
this type of impeachment evidence.  To the extent that Wolfe and cases following it hold 
that a witness may not be impeached by asking him or her about specific instances of 
conduct relevant to his or her character for truth and veracity, it no longer should be 
followed.9   
Applying these principles here, the trial court erred in ruling that Missouri law did 
                                             
 
9 Cases citing and applying or distinguishing this statement in Wolfe include decisions of 
this Court, see, e.g., State v. Couch, 256 S.W.3d 64, 69 (Mo. banc 2008) (quoting rule), 
and Wilson, 256 S.W.3d at 61 (quoting rule), as well as those of the court of appeals, 
see, e.g., State v. Corwin, 295 S.W.3d 572, 579 (Mo. App. 2009) (refusing to allow 
cross-examination of complaining witness about specific instances of her conduct); State 
v. J.L.S., 259 S.W.3d 39, 48 (Mo. App. 2008) (quoting rule but admitting evidence as 
proof of bias as means of avoiding rule); and Kuehne v. State, 107 S.W.3d 285, 294 
(Mo. App. 2003) (same). 
 
19
not permit plaintiffs’ counsel to ask Dr. Kardesch about his prior false interrogatory 
answer and his deposition admissions and explanations of it because the subject of that 
false answer – that his medical license had been suspended – was not independently 
admissible; therefore, the whole issue was “collateral.”  Cross-examination may be had 
on issues relevant to the witness’s character for truth and veracity regardless of whether 
the subject of the falsehood is material.  See, e.g., Zahn, 823 S.W.2d at 22; Roberts v. 
Emerson Elec. Mfg. Co, 362 S.W.2d 579, 584 (Mo. 1962). 
While the trial court, in the exercise of its discretion, can limit the admission of 
evidence if on balance its prejudicial value outweighs its probative value, here plaintiffs 
agreed to abide by the trial court’s ruling that they could not introduce evidence 
concerning the criminal case that formed the underlying reason for the suspension nor 
would they imply the suspension was related to Dr. Kardesch’s medical ability.  Plaintiffs 
offered to work with the court and opposing counsel (and had worked out a tentative 
agreement) to introduce this evidence in the least prejudicial way – one that would permit 
them to make their argument that Dr. Kardesch hid the two-year suspension of his 
medical license due to embarrassment; although it did not reflect on his ability to practice 
medicine it did reflect on whether his version of events in regard to his treatment of Mr. 
Mitchell also was affected by his desire to hide facts so as to avoid embarrassment. 
On these facts, the trial court abused its discretion in prohibiting counsel from 
examining Dr. Kardesch about his statements about his suspensions in his interrogatory 
answer and deposition. 
 
 
20
C. 
Use of Extrinsic Evidence To Impeach Character for Truth and Veracity  
The rules regarding admission of extrinsic evidence fall into two categories 
depending on the method of impeachment employed.   
Parties are permitted to introduce extrinsic evidence to impeach a witness by 
showing his or her inability to perceive the events testified to; prior convictions; or to 
show bias, prejudice or interest in the proceeding, regardless of whether the subject of the 
extrinsic evidence is independently material to the case.  See, e.g., State v. Johnson, 706 
S.W.2d 815, 817-18 (Mo. banc 1985) (bias); State v. Pigques, 310 S.W.2d 942, 947 
(Mo. 1958) (bias); State v. Caston, 509 S.W.2d 39, 41 (Mo. 1974) (ability to perceive). 
By contrast, parties traditionally have been limited in introducing extrinsic 
evidence when the form of impeachment concerns the witness’s prior inconsistent 
statements or the witness’s character for truth and veracity.  They generally may do so 
when the witness denies the prior statement or specific instance of conduct only if the 
subject of the impeachment is material to the issues rather than collateral. 
As this Court stated in Black, collateralness goes to relevancy: “A matter is 
considered to be collateral if the fact in dispute is of no material significance in the case 
or is not pertinent to the issues developed. … If a fact may be shown in evidence for any 
purpose independent of contradiction, it is not collateral.”  151 S.W.3d at 55.  Black 
applied these principles to the case before it, holding that the trial court abused its 
discretion in excluding extrinsic evidence in the form of three witnesses’ prior statements 
that were inconsistent with their in-court testimony because the subject of the inconsistent 
statements was material.  Id. at 55-56.  
 
21
Where the subject of the extrinsic evidence is “collateral” to the substantive issues 
at trial, however, then normally “the defendant’s answer with regard to his knowledge or 
denial of the questioned conduct is binding on the [questioner] and precludes further 
inquiry or extrinsic proof.”  Carothers, 710 S.W.2d at 371.  As State v. Long noted, this 
rule “furthers the general policy focusing the fact-finder [on] the most probative facts and 
conserving judicial resources by avoiding mini-trials on collateral issues.”  140 S.W.3d 
27, 30 (Mo. banc 2004). 
But Long held that in the case before it, fairness required it to recognize an 
exception to the rule prohibiting extrinsic evidence of nominally nonmaterial issues.  It 
permitted the defendant to introduce “the testimony of three witnesses who said that the 
victim had made previous false allegations of sexual or physical assault,” stating: 
In some cases, however, the rule excluding extrinsic evidence of prior false 
allegations fails to serve this purpose [of focusing the jury on the central 
issue] by shielding the fact-finder not from collateral issues, but from a 
central issue in the case.  An issue is not collateral if it is a ‘crucial issue 
directly in controversy.’ 
 
Id.  Long, therefore, concluded that extrinsic evidence of prior false allegations should be 
admissible because relevant to the central issue of credibility: 
Where, as in this case, a witness’ credibility is a key factor in determining 
guilt or acquittal, excluding extrinsic evidence of the witnesses’ prior false 
allegations deprives the fact-finder of evidence that is highly relevant to a 
crucial issue directly in controversy; the credibility of the witness. 
 
Id. at 30-31. 
This Court’s decision in Roberts, 362 S.W.2d at 584, similarly had permitted 
extrinsic evidence in the form of deposition testimony of plaintiff to be used to impeach 
 
22
plaintiff’s testimony at trial that all of his lawyers had “joined the mob” who were against 
him.  The Court stated that, while “the relationship between plaintiff and his lawyers and 
counsel for defendant, strictly speaking, was immaterial,” plaintiff’s lack of ability to get 
along with his lawyers and others as well as his persecution complex and belief in a 
conspiracy against him “would be of value to the jury in assessing and evaluating 
plaintiff’s essential soundness, credibility and reliability as a witness.”  Id. 
These cases approve exceptions to the bar on extrinsic evidence of a witness’s 
character for truth and veracity where the evidence in question, even if not dealing with 
the substantive issues in the case, is very probative of and relevant to credibility.  The 
difficulty with this approach is that it does not assist litigants or the courts in defining 
when credibility is to be considered central and therefore subject to being shown through 
extrinsic evidence, and when not.  An analogy can be drawn, however, to cases 
permitting the admission of extrinsic evidence showing a witness’s bias, prejudice, 
interest, prior convictions or inability to perceive; the rationale on which the latter cases 
rely is the same as that used in Long to justify introduction of extrinsic evidence of a 
witness’s character for truth and veracity.  
As a result, in State v. Solven, 371 S.W.2d 328 (Mo. banc 1963), this Court held 
that evidence of bias, prejudice or interest is always relevant: 
The interest or bias of a witness and his relation to or feeling toward a 
party are never irrelevant matters, and where the interest or bias is denied 
by the witness, it may be shown by the testimony of others, and even where 
such interest or bias is admitted by the witness, the extent of it may be 
shown, though much is left to the discretion of the trial court as to how far 
the inquiry may go into the details of the difficulty, disagreement or other 
transaction which caused the hostility, prejudice or ill feeling. 
 
23
 
Id. at 331 (emphasis added).  State v. Edwards, 637 S.W.2d 27, 29-30 (Mo. 1982), and 
State v. Johnson, 700 S.W.2d 815, 817 (Mo. banc 1985), reaffirm that extrinsic 
evidence showing bias or interest is never irrelevant and is admissible subject to the trial 
court’s discretion to avoid undue prejudice.10
Similarly, Lagud held that where the extrinsic evidence goes to the witness’s 
intoxication or similar reasons that affect the witness’s perception, then “the subject of 
the witness’s testimony is not a collateral issue but bears directly on the ability of the 
witness to accurately describe those events.” 136 S.W.3d at 793.  Accord, State v. 
Caston, 509 s.W.2d 39, 41 (Mo. 1974).   
The focus of both exceptions is the need to admit highly probative and relevant 
evidence for the jury’s consideration in determining whether to credit a witness’s 
testimony.11  An important distinction nonetheless does exist between cases involving 
extrinsic evidence of bias as compared with cases involving extrinsic evidence of 
                                             
 
10 See also 3A WIGMORE ON EVIDENCE, §§ 1020 at 1011 (Chadbourn rev. 1970) (“an 
important class of matter clearly admissible, namely, facts relating to bias, corruption, or 
other specific deficiencies of the witness.  It is not merely matters which are a ‘part of the 
case,’ that may be the subject of self-contradiction, but any matter which would have 
been otherwise admissible in evidence.”  Wigmore continues, “In applying the foregoing 
test, it is obvious that there are two classes of facts of which evidence would have been 
admissible independently of the self-contradiction: (1) facts relevant to some issue in the 
case under the pleadings; (2) facts admissible to discredit the witness as to bias, 
corruption, or the like.”  Id. § 1021 at 1011). 
11  In fact, in State v. J.L.S., 259 S.W.3d 39, 48 (Mo. App. 2008), the court of appeals 
noted that prior cases had avoided the need addressed in Long to adopt an exception to 
the rule excluding extrinsic evidence as to character for truth and veracity by simply 
stating that prior false allegations are admissible to show bias. Logically, however, such 
allegations do not address bias but a willingness to accuse falsely; prior cases simply 
 
24
character for truth and veracity.  That distinction may explain why, historically, extrinsic 
evidence has not been permitted in the latter instance.  For while the bias of a testifying 
witness toward a party or issue is nearly universally going to be highly relevant and 
probative because it will affect whatever issue the person is testifying about, the same 
may not always be true concerning extrinsic evidence of character for truth and veracity.  
This is because the fact that a person has told a lie on an irrelevant issue that is remote in 
time or subject may make the extrinsic evidence of little value in determining the 
witness’s character for truth and veracity.  As a result, the cases have adopted a general 
rule prohibiting such evidence because in most instances the risk of prejudice and the 
distraction of a mini-trial would outweigh the benefit of allowing such evidence.12
The adoption of ad hoc exceptions in cases such as Long and Roberts, however, 
indicates that the better rule, and one that would provide more consistent guidance, would 
be to recognize that the real issue to be decided by the trial court is whether admission of 
the extrinsic evidence would be more probative or more prejudicial.  In cases involving 
character of the witness for truth and veracity, it will be the unusual case where that 
balancing weighs in favor of admission of extrinsic evidence.  But where it does so, such 
evidence should be admitted. In Long, therefore, because the extrinsic evidence 
concerned prior false allegations to authorities of a matter similar in nature to the alleged 
                                                                                                                                                 
 
were attempting to get around the rule excluding what was otherwise very probative and 
relevant evidence.   
12 For instance, in Wilson, 256 S.W.3d at 62, this Court held that even cross-examination 
of a child victim of a sex crime about whether she had lied to her mother about who 
crashed the family car was inadmissible because its potential prejudice far outweighed its 
probative value. 
 
25
wrongful conduct in which the witness claimed defendant engaged, the truthfulness of the 
witness was highly relevant and probative to the credibility of the case’s key witness.  
Although Long did not expressly weigh the probative value against any prejudice of the 
evidence, it in effect held that where the evidence is so highly probative and relevant, the 
court abused its discretion by excluding it.  
Applying these rules regarding admission of extrinsic evidence here, plaintiffs 
sought to impeach the defendant’s character for truth and veracity by presenting extrinsic 
evidence of Dr. Kardesch’s own statements under oath in this very case showing he gave 
a false answer in an interrogatory asking whether his license to practice medicine had 
been suspended.  The probative value and relevance of his willingness to answer this 
interrogatory falsely (if such is shown) is high.  This is so not because the suspension 
itself is highly relevant (it is not as it was based on a ground not related to the doctor’s 
medical ability) but because it showed the defendant was willing to dissemble to hide 
facts about his medical background that he found embarrassing.  This reflects on the 
credibility of his testimony at trial about what he told Mrs. Mitchell and whether his 
testimony was accurate or was offered instead to avoid embarrassment.  On these facts, 
the trial court abused its discretion in entirely excluding such extrinsic evidence. 
IV. 
SUFFICIENCY OF EVIDENCE  
 
 
Dr. Kardesch argues that even assuming arguendo that it was error for the trial 
court to exclude the evidence that he had given a false sworn interrogatory answer in this 
case, the error was not prejudicial.  Although he does not phrase this argument as one 
addressing the sufficiency of the evidence, this is the necessary intendment of Dr. 
 
26
Kardesch’s argument, for it is his position that even if all facts are to be viewed in the 
light most favorable to Mrs. Mitchell:  (1) there is no genuine issue of material fact 
relating to whether Dr. Kardesch acted within the appropriate standard of care, and/or (2) 
reasonable minds could not differ in concluding that Dr. Kardesch acted within the 
appropriate standard of care.  While Dr. Kardesch clearly believes he should win on the 
merits, a case will be taken out of the jury’s hands only if there is no genuine issue of 
material fact and the moving party is entitled to judgment as a matter of law, ITT 
Commercial Fin. Corp. v. Mid-Am. Marine Supply Corp., 854 S.W.2d 371, 376 (Mo. 
banc 1993), Rule 74.04(c)(6), or if reasonable minds, in viewing the evidence in the light 
most favorable to the non-moving party, only could find in the moving party’s favor.  
Edgerton v. Morrison, 280 S.W.3d 62, 68 (Mo. banc 2009); Clevenger v. Oliver Ins. 
Agency, Inc., 237 S.W.3d 588, 590 (Mo. banc 2007). 
Here, however, Mrs. Mitchell presented expert testimony, set out in detail above, 
that Dr. Kardesch’s failure to send Mr. Mitchell to the emergency room or to a specialist 
for treatment when Mrs. Mitchell first called, and the failure to follow up with a 
cardiologist following the stress test, failed to meet the standard of care and to a 
reasonable degree of medical certainty caused Mr. Mitchell’s injury and death.  That Dr. 
Kardesch does not believe these opinions are credible does not mean the jury could not 
find them credible.  Factual determinations of matters in dispute, including the weighing 
of medical opinions, rest solely within the province of the jury.  See In re Care and 
Treatment of Spencer, 123 S.W.3d 166, 168 (Mo. banc 2003).  It “is error for the court 
to declare as a matter of law a result or legal effect which is within the exclusive province 
 
27
of the jury to determine.”  Glowacki v. Holste, 295 S.W.2d 135, 139 (Mo. banc 1956). 
V.   
CONCLUSION  
For all of the reasons stated above, the circuit court’s judgment is reversed, and the 
case is remanded.  If a new trial occurs, plaintiffs may cross-examine Dr. Kardesch about 
his interrogatory answer and, if necessary, impeach him with it and with his deposition 
testimony, subject to the trial court’s exercise of discretion to limit such testimony so as 
to avoid distraction of the jury or undue prejudice to Dr. Kardesch. 
 
 
 
 
 
 
 
 
_________________________________ 
LAURA DENVIR STITH, JUDGE 
 
 
All concur. 
 
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