Opinion ID: 2224042
Heading Depth: 1
Heading Rank: 1

Heading: Treating Doctors' Testimony

Text: Dr. Frank, an internist engaged in family practice, testified that he saw Mrs. Hinlicky approximately once a year starting in September 1984, primarily for treating her high blood pressure. In 1993, she complained of shortness of breath, exhaustion and chest pain, which she believed began after shoveling heavy snow in her driveway. Dr. Frank ordered an electrocardiogram (EKG), which showed a benign condition resulting from her longstanding hypertension; he diagnosed and treated gastritis and gallstones, concluding that her heart was not at risk, and her symptoms improved. In 1995, he ordered a second EKG after she complained of discomfort in her left arm and chest. The result was similar to the earlier test, and Dr. Frank determined that her symptoms were not cardiac in nature. She reported that her symptoms cleared with hot soaks and Tylenol. In August 1996, during a routine checkup, Mrs. Hinlicky reported that her sister recently had carotid artery surgery and her brother a heart bypass. Based on a physical examination, Dr. Frank testified that he grew concerned that she might have blockages in her carotid arteries, obstructing the blood-flow to her brain, and indeed an ultrasound test showed significant blockages in both. In a follow-up appointment, Dr. Frank concluded that occasional episodes of decreased vision in Mrs. Hinlicky's right eye were symptoms of a condition associated with the blocked carotid artery and he referred her to the larger, regional hospital for a surgical evaluation. After his own examination and review of the ultrasound, Dr. Dreyfuss, a vascular surgeon, ordered a third EKG, a chest X-ray, blood tests and an angiogram revealing a 70%-to-75% blockage of the left carotid artery and more mild blockage of the right. He recommended an endarterectomyan operation he had performed hundreds of timesand explained that without the surgery, she faced the possibility of a stroke. He testified that it was his practice to order invasive cardiology workups on patients who previously had heart attacks, open-heart surgery and episodes of congestive heart failure, but concluded that was unnecessary because Mrs. Hinlicky had never had a heart attack, she was taking only a mild anti-[hyper]tensive medication, wasn't taking digoxin or medication to help her heart pump harder, didn't have . . . congestive heart failure, had a cardiogram that had been stable for a period of three years and didn't have any active chest pain. Dr. Dreyfuss did not order a stress test or angioplasty because, he testified, they presented risks that in her case had little likelihood of benefit or changing his prescribed therapy. Dr. Ilioff, the anesthesiologist, testified that he reviewed Mrs. Hinlicky's medical history, her chart, the laboratory results, EKGs from 1995 and 1996, and two preoperative nursing assessments, and that he examined and interviewed her. Specifically, he questioned her regarding potential coronary ischemia (lack of blood-flow to the heart) and assigned her a value of three on the American Society of Anesthesiologists' scale for surgerymeaning she had a severe systemic disease which he described as a blockage in the vessel in her neck. [2] He explained that he decided not to send her for a preoperative cardiac evaluation based on the type of surgery involved, her history and her functional capacity. After testifying at length concerning the steps leading to his decision not to refer Mrs. Hinlicky for preoperative cardiac testing, Dr. Ilioff noted that he had followed a set of clinical guidelines published in 1996 by the American Heart Association (AHA) in association with the American College of Cardiology (ACC). He testified without objection that he incorporated the guidelines into his practice shortly after they were published, because they helped physicians decide which patient needs to go for a cardiac evaluation . . . and which patient can proceed to the operating room, and he identified proposed Exhibit C as the AHA/ACC flow diagram that [he] used and continued to use to evaluate patients for pre-operative need for cardiac evaluation. (Neither of the physician defendants who testified before Dr. Ilioff, in describing the basis for their decision not to refer Mrs. Hinlicky for preoperative cardiac testing, mentioned the algorithm.) When defense counsel asked Dr. Ilioff for background on the guidelines, plaintiff objected to any testimony that would involve a discussion of what others have stated or what others have done. That is clearly hearsay. The trial court speculated as to whether we need to get into the basis for the program he followed. It would involve other testimony by other experts and perhaps the objection is well founded in that regard. This colloquy ensued: [DEFENSE COUNSEL]: And that is true, I believe, your Honor, but inasmuch as Dr. Ilioff has indicated that he utilized these guidelines himself, I believe it would be pertinent at this time to review those with him and that's what I'm attempting to do, to lay the foundation with respect to those guidelines. THE COURT: Well, I think perhaps if he can tell us the prominence of the conclusion they reached rather than going in to what they did to reach the conclusion that would perhaps obviate the hearsay problems. [PLAINTIFF'S COUNSEL]: I don't have any problem if he wants to testify about his practice and how he conducts his practice. But it's improper to be testifying about what others have stated with respect to any of that. After an off-the-record sidebar, Dr. Ilioff testified without further objection that the algorithm was a flow diagram. And it helps us in a decision making process. Helps us decide what patients to send to the operating room, what patients to send to the cardiologist. According to the witness, the algorithm was commonly used by anesthesiologists but was also available to surgeons, internists and family physicians, and he would consult it for patients like Mrs. Hinlicky who were at risk for coronary artery disease to determine the need for cardiac evaluation. When defense counsel offered the algorithm into evidence, plaintiff objected on the ground that: this is a document taken from some other document. This is a chart taken from some other document. It's clearly hearsay in nature. And I believe that the witness can testify as to what guidelines he uses and how he uses them, but to use the chart, I think, is improper. As itself it is hearsay, that's my objection. THE COURT: Well, I think it probably is technically speaking hearsay, but I think it's a classic case for the use of the professional reliability exception to that rule. It is a document, as I understand it, which does not purport to resolve any crucial issue in the case. It's to be used only to explain an evaluation procedure [ ] which a treating doctor used, as merely one link in the chain [ ] which he relied upon to reach a conclusion. It is according to the testimony I've heard from the witness a material reasonably relied upon by anesthesiologists and others who do pre-operative assessments of a patient who [is] at some risk for coronary artery disease, is that true? THE WITNESS: That's correct. THE COURT: I'll allow it under the professional [re]liability exception to the rule against hearsay. [3] Dr. Ilioff then testified that the chart provided a list of variables, the presence or absence of each variable pointing toward surgery or cardiac evaluation. The witness explained that he went through each step of the chart and, based on his assessment of the variables, concluded that there was no need for a cardiac evaluation. He did not consider factors that were not on the chart, because in his opinion, such factors do not make a difference in the patient's outcome. Plaintiff called three medical experts, and defendants four. While not disputing the reliability of the algorithm, six of the seven expert witnesses clashed over its significance as the standard of care.