Opinion ID: 2785779
Heading Depth: 2
Heading Rank: 1

Heading: Fergen v. Sestero

Text: In November 2004, Paul Fergen found a small lump on his ankle that was causing slight discomfort. The next week he went to see Dr. John Sestero regarding the lump. Sestero completed a physical examination of the ankle and described the lump in his chart notes as a slight nodule that was smooth, soft, and nontender. Fergen Ex. (FE) P-1, at 12. Fergen was not experiencing any redness, swelling, or other abnormalities. Sestero assessed it as a ganglion cyst, 2 ordered an X ray to make sure there were no structural defects, referred Fergen to an orthopedic specialist, and instructed him to follow up with his office as necessary. The X ray confirmed an absence of any problems in the ankle, but the radiologist noted, If a soft tissue cyst is felt an ultrasound might be ofhelp. FE P-1, at 155. Sestero informed Fergen that the X ray was negative but did not order an ultrasound. Approximately 13 months later, Fergen suffered a seizure. Thereafter, he was diagnosed with Ewing's sarcoma, a rare and aggressive form of metastatic cancer 2 Sestero's notes did not say benign explicitly, but a ganglion cyst is a fluid-filled cyst that is considered to be benign. 3 Fergen v. Sestero, No. 88819-1 that originated in the lump on his ankle. After an extended course of treatment involving radiation and chemotherapy, Fergen died. Sestero's records do not contain any indication that he entertained diagnoses of the lump other than a ganglion cyst. During trial, he testified as to his use of clinical judgment during his thought process that day, including why he believed it to be a cyst and why he ordered certain tests. He testified that malignancy is a consideration anytime you see a lump, although he never specifically said he considered it that day. 4 Fergen Verbatim Report of Proceedings at 609. Defense medical experts testified that the applicable standard of care did not require Sestero to order an ultrasound, biopsy, or other test to rule out cancer, or to make a referral to a specialist, or even to X ray the lump. Dani Fergen, individually and as personal representative of the estate of Paul Fergen, as well as their minor children, Brayden Fergen and Sydney Fergen, individually filed suit against Sestero and his employer, Spokane Internal Medicine PS, alleging negligence and breach of the standard of care for failing to take the steps necessary to ensure that the lump on Fergen's ankle was, in fact, a benign ganglion cyst. Fergen says Sestero simply diagnosed it as a benign cyst without considering other diagnoses or doing anything to confirm or disprove that the lump was benign and thus there is no evidence of a conscious choice. Sestero countered that his diagnosis of a benign cyst inherently involved the exercise of clinical judgment since 4 Fergen v. Sestero, No. 88819-1 selection of one diagnosis necessarily entails the rejection of other possible, less likely, diagnoses. The trial judge gave the jury instruction on a physician's exercise of judgment. It read, A physician is not liable for selecting one of two or more alternative diagnoses, if, in arriving at a diagnoses a physician exercised reasonable care and skill within the standard of care the physician was obligated to follow. Fergen Clerk's Papers at 3198. The jury found for the defendant, and Fergen appealed. The Court of Appeals affirmed. Fergen v. Sestero, 174 Wn. App. 393, 398, 298 P.3d 782 (2013). We granted Fergen's petition for review. Fergen v. Sestero, 178 Wn.2d 1001,308 P.3d 641 (2013).