Opinion ID: 1489278
Heading Depth: 1
Heading Rank: 6

Heading: The Directed Verdicts and the Anticipated Testimony of Dr. Pennanen

Text: On the fourth day of trial, all of the defendants moved for directed verdicts, [32] arguing that Coulter would not be able to establish through expert testimony a breach of the national standard of care or causation. As already described, Coulter's expert Dr. Woodyear was not permitted to testify beyond voir dire, her expert Dr. Abel was qualified to provide expert testimony only as to oncology and not as to any breach of the national standard of care, and Coulter was not permitted to read the deposition testimony of Dr. Haines into the record. The other witnesses that Coulter had presented  Dr. Taylor and Dr. Fullum  did not acknowledge that they had breached the national standard of care. Coulter planned to call one more expert, surgeon Dr. Pennanen, and possibly a lay witness (Ms. Thomas), and she planned to testify herself. Dr. Pennanen had been engaged to provide expert testimony regarding the care by Dr. Fullum only. Coulter's counsel argued that directed verdicts would be premature because (1) Coulter would testify that Dr. Taylor examined her breast with one finger, (2) there was ample testimony as to what the standard-of-care breast examination consist[s] of, [33] and (3) the jury could find that Dr. Taylor was careless, both in the method that he used to examine Coulter's breast and by not re-examining the lump [34] during Coulter's subsequent visits to him. But, to prevail, Coulter was required to show that any deviation by Dr. Taylor from the standard of care caused damages, and Coulter had no witness who testified (or, in the case of Dr. Pennanen, would testify) that any negligence by Dr. Taylor in August 2001 worsened Coulter's prognosis, caused her to need a more invasive treatment, or otherwise contributed to her injury. Similarly, although Coulter argues that the jury could have found that Dr. Asomani did not expedite ... Coulter's referral [to] specialist care, Coulter had no witness who testified (or would testify) that any delay on Dr. Asomani's part either breached the standard of care or was a cause of Coulter's damages. Conducting a de novo review of whether Coulter established a prima facie case, see Snyder, supra, 890 A.2d at 245, we conclude on this record that directed verdicts were warranted as to Gerald Family Care and as to Drs. Taylor and Asomani. It was clear that Coulter would not be able to meet her burden of proof as to any of these defendants/appellees through the testimony of her remaining, lay witnesses. Even though Coulter did not complete presentation of her case-in-chief, we are satisfied that, as to the potential liability of these defendants, she was fully heard. Super. Ct. Civ. R. 50(a)(1); see also Super. Ct. Civ. R. 50(a)(2) (providing that a motion for judgment as a matter of law may be made at any time before submission of the case to the jury). Accordingly, we affirm the entry of the directed verdict as to defendants/appellees Gerald Family Care, Dr. Taylor, and Dr. Asomani. Our resolution as to Dr. Fullum requires some additional background explanation, both about the expected testimony of Dr. Pennanen [35] and about the colloquy that led to the trial court's ruling that prevented her from testifying and to the directed verdict. As we explain infra, taken together, Dr. Pennanen's (anticipated) testimony about the expedited diagnostic procedures that the standard of care required in the absence of extenuating patient circumstances; Dr. Fullum's testimony about his reason for not expediting performance of those diagnostic procedures (which was that there was no rush) and his failure to identify any extenuating patient circumstance that necessitated delay; and Dr. Pennanen's (anticipated) testimony about the adverse impact that the delay had on Coulter's prognosis, would have enabled Coulter to establish prima facie a case of medical malpractice by Dr. Fullum. We are also satisfied that, contrary to the representations that Dr. Fullum's counsel made to the trial judge, Dr. Fullum would not have been ambushed had Dr. Pennanen been permitted to testify. We therefore conclude that the trial court should have permitted Dr. Pennanen to testify, notwithstanding her statement during her deposition that she would not offer an opinion that Dr. Fullum deviated from the standard of care. Dr. Pennanen testified at her deposition that she is an Associate Professor on the faculty at Georgetown University Medical Center and a breast surgeon specializing in breast disease diagnosis and treatment. She spends the majority of her time in the clinical care of patients, does research on breast cancer prevention, diagnosis and treatment and breast cancer risk assessment, and teaches and publishes in those same areas. Dr. Pennanen characterized the findings of Coulter's ultrasound from December 2002  which measur[ed] something discrete and showed echogenic irrregularity in the left breast  as abnormal, an indication of something that possibly might not be benign. She explained that in this situation, the procedure called for wouldn't be a screening mammogram ... because she has an abnormality. So it would be a diagnostic mammogram. A screening mammogram is for someone who is asymptomatic. Having reviewed Coulter's medical records, Dr. Pennanen testified that there were significant delays specifically from the time [Coulter] initially saw Dr. Fullum until her mammogram was obtained and then again from the time of her post-operative visit after the biopsy when the pathology of the biopsy was available until she had her definitive surgery, the mastectomy. She stated that the standard of care for the length of time between the initial surgical consultation visit and the time of a mammogram in a patient such as Sanya Coulter is [w]ithin two to three weeks. [36] Of particular significance, she explained that more than two weeks would be unusual ... unless there was some kind of extenuating circumstance like the patient was out of town and did not choose to schedule it then. She also explained that you can get a report on a mammogram the same day that it is done. The following exchange occurred between Coulter's counsel and Dr. Pennanen: Q: Dr. Fullum said that on January 30th he went out and told his office staff people to schedule this thing for a screening mammogram instead of a diagnostic mammogram. Given those circumstances, did that make any sense? A: No. Dr. Pennanen further testified that it is likely that if [Coulter] had been treated at an earlier time, her prognosis would be different; that it is probable that the number of involved [lymph] nodes increased... between January and June [the time period when Coulter was under Dr. Fullum's care], and is likely that the tumor increased in size between January and June, putting Coulter in a different prognostic category; and that it is likely that [Coulter] had fewer [lymph] nodes involved in the first one to two months under Dr. Fullum's care, that she had more nodes involved in the last one to two months, and that the increase would have a 20 percent detrimental effect on her prognosis. Dr. Pennanen testified in addition that it was probable that Coulter's chance for a five year disease free survival decreased under Dr. Fullum's care. But Dr. Pennanen did not know the circumstances as to why there was a delay from the time [Coulter] was initially seen by [Dr. Fullum] until she had the mammogram and the same with respect to the post-operative visit and her definitive surgery and therefore could not say what the cause was or attribute it to Dr. Fullum. On the morning when Coulter expected to call Dr. Pennanen, Judge Combs Greene inquired into whether Dr. Pennanen would offer an opinion that Dr. Fullum deviated from the national standard of care. Coulter's counsel told the court that Dr. Pennanen's overall deposition is consistent that Doctor Fullum violated the standard of care. Reading from portions of the deposition transcript, Judge Combs Greene then noted that at Dr. Pennanen's deposition, defense counsel had asked her whether she felt she had the information she required to come to a conclusion and opinion regarding whether Doctor Fullum complied with the standard of care, and that Dr. Pennanen had responded, No..... I know that there were these delays [in scheduling the diagnostic procedures and mastectomy, but] as to why that happened I cannot address that. Judge Combs Greene also noted that in answer to the question Do you expect to express the opinion at trial that Doctor Fullum violated the standard of care? Dr. Pennanen said At this point I do not. I haven't seen Doctor Fullum's testimony and I don't know the details of why there were these delays. The following exchange ensued: Coulter's Counsel: Your Honor, the jury has heard Doctor Fullum's testimony and Doctor Pennanen will establish the standard of care and the jury will be able to determine that he was, therefore, negligen[t]. The Court: So if I called her in now and out of the presence of the jury voir dired her she would now surprisingly say that she's going to offer an opinion that Doctor Fullum deviated from the standard of care? ... Coulter's Counsel: Yes. The Court: Let's call her in. At this point in the proceedings, Dr. Fullum's counsel strenuously object[ed], telling the court that Dr. Fullum would be totally ambushed if Dr. Pennanen was allowed to offer an opinion that she had said, during discovery, she would not give. The following colloquy ensued between Coulter's counsel and the court: Coulter's Counsel: There's no ambush Your Honor  The Court: Oh, there clearly is, ... She's says right here she's not going to offer an opinion. So these folks  [Dr. Fullum's counsel] is thinking on behalf of his client that he doesn't have to deal with that and now a minute before she's supposed to testify you inform me that she is going to offer an opinion. Coulter's Counsel: She [has] always done so, Your Honor. The Court: Where is it? Show me in her deposition where it is.... Coulter's Counsel: Your Honor, in her deposition she set up  she stated that Doctor Fullum unnecessarily  Doctor Fullum delayed the surgery. And whether he was negligent depended upon whether he had reason for that delay. As the colloquy went on, Judge Combs Greene repeatedly asked Coulter's counsel to show her where in the deposition transcript Dr. Pennanen testified to a deviation from the standard of care. Coulter's counsel responded by asking the court to voir dire Dr. Pennanen or to read her whole deposition and not rely upon a line. He told the court that during Dr. Fullum's testimony, Dr. Fullum ... supplied the reason for his delay and then argued: Coulter's Counsel: Your Honor, a Plaintiff is entitled to prove standard of care violations by proving the standard of care and the Court may then allow the jury to compare the Defendant's conduct against the proven standard of care and the jury can then decide whether there was a violation. It's not necessary that a physician testify specifically that there was a violation, it is sufficient that the physician offer the standard of care and the information  The Court: You're just wrong  you're just wrong on that, Mr. Shepherd. The Court then concluded: Based on the Court's reading of at least this portion of the deposition, the failure of Plaintiff's counsel to advise the Court of any other place in the deposition where there would be testimony that Doctor Fullum deviated from the standard of care, the motion of the Defendant to preclude any now new testimony the Court will grant that motion because it would be surprise testimony, it would be a failure for the Plaintiff to have abided by the rules to supplement any additional opinions by expert testimony and the Court will preclude Doctor Pennanen's testimony. Thereafter, the court entered a directed verdict in favor of Dr. Fullum. On appeal, Coulter renews her argument that the trial court erred in not permitting Dr. Pennanen to testify, contending that Dr. Pennanen could have define[d] the standard of care applicable to Dr. Fullum at trial for the jury to apply to the evidence. Coulter argues that this is a case where the jury could equally well as the expert, apply the standard to the evidence and determine whether there was a breach or compliance. In light of our case law, the particular facts of this case, and Dr. Pennanen's deposition testimony, we are persuaded by Coulter's argument. As already discussed, in general, expert testimony is needed to establish that there was a deviation from the national standard of care. That is because, where the claim presented is that plaintiff was injured as a result of the negligent exercise of medical judgment, resolution of the issue generally requires knowledge and judgment that is beyond that of the average jury of lay persons. But the scope of the required expert testimony depends on the particular issues to be resolved by the trier of fact. Washington Hosp. Ctr. v. Martin, 454 A.2d 306, 308 (D.C.1982). In Martin, the plaintiff, who had been hospitalized while recovering from hip surgery, alleged that the hospital was negligent in failing to protect her from falling out of bed. We explained that expert testimony would have been necessary to establish negligence if the issue in the case had been whether the doctor correctly prescribed restraints for appellee or whether the nursing staff applied them properly, because [t]hose are matters which generally involve professional judgment and skill, and if the exercise of such judgment and skill is at issue, expert testimony would no doubt be needed.... Id. We reasoned, however, that as to the central issue of whether the plaintiff was in fact under restraints immediately prior to her fall, that was not a question on which expert testimony was either necessary or helpful. Id. We agree with Coulter that a similar analysis is appropriate in this case. As already described, Dr. Pennanen opined that Coulter, referred to Dr. Fullum in December 2002, because of an abnormal sonogram, required a prompt diagnostic mammogram rather than a screening mammogram, and that the standard of care called for obtaining the diagnostic mammogram within a few weeks unless there was some reason for delay, such as the patient's need to be out of town. Dr. Pennanen was unable to say what had caused the mammogram to be delayed (until March 21, 2003). Coulter's counsel sought to juxtapose Dr. Pennanen's testimony against Dr. Fullum's trial testimony, telling the court  as noted supra  that the jury has heard Doctor Fullum's testimony and Doctor Pennanen will establish the standard of care and the jury will be able to determine that he was, therefore, negligen[t]. During his trial testimony, Dr. Fullum acknowledged that Coulter has been referred to him for a consultation regarding a breast mass, that he reviewed Coulter's sonogram sometime prior to her initial visit with him on January 30, 2003, and that the sonogram showed echogenic irregularities in the left breast. The jury heard him testify that he directed his staff to schedule Coulter for a general screening mammogram to be done prior to her follow-up appointment in three months, because there was no rush. Scheduling the mammogram within three months was acceptable since Dr. Fullum detected nothing that caused him to be concerned and did not view the sonogram, which showed a mild irregularity, as presenting an emergency. [37] Had jurors heard Dr. Pennanen's testimony, they could have credited her opinion that, absent extenuating patient circumstances, the standard of care required Dr. Fullum promptly to order a diagnostic (rather than screening) mammogram when he saw the ultrasound showing echogenic irregularities of the left breast. Jurors could then have found on the basis of Dr. Fullum's (and Coulter's) testimonies that there was no such extenuating patient circumstance that necessitated a delay in scheduling of the mammogram. Rather, the jury could have found, the delay was attributable to a breach of the standard of care entailed in Dr. Fullum's failure to order an expedited diagnostic procedure. Cf. Ferrell v. Rosenbaum, 691 A.2d 641, 649 (D.C.1997) (Although Dr. Rosenbaum did not make an admission as to the ultimate issue of breach of the standard of care, he testified that the fact that his notes did not indicate that he had seen the blood work probably meant that he had not reviewed the blood data. This testimony was enough to raise a question of material fact as to breach of the standard of care.... Dr. Rosenbaum's deposition testimony, in the context of the expert testimony concerning the applicable standard of care, was sufficient to defeat summary judgment.). Whether Coulter was out of town or presented some other kind of extenuating circumstance that necessitated a delay in scheduling the mammogram  the particular issue[ ] to be resolved by the trier of fact in determining whether there was a breach of the standard of care, Martin, supra, 454 A.2d at 308  was an issue that the jury was competent to handle, without the need for expert testimony that went beyond what Dr. Pennanen offered during her deposition. [38] It was not necessary for Coulter's case that Dr. Pennanen state definitively that Dr. Fullum violated the standard of care. [39] Cf. Kaminski v. Duane, 754 D.2d 375, 1984 U.S.App. LEXIS 13531,  (6th Cir.1984) (applying state law that does not require the expert witness to state explicitly that the defendant violated an applicable standard of care so long as the expert provides sufficient evidence of prevailing standards and the jury has other evidence which demonstrates that a departure from the standards of care actually did occur), citing Baldwin v. Williams, 104 Mich.App. 735, 306 N.W.2d 314, 316 (1981) (this Court has not required that an expert witness testify that a breach has occurred in a case where the expert stated the applicable standard of care and other factual testimony elicited at trial established what procedure was actually followed by the defendant); Knutson v. Sand, 282 A.D.2d 42, 725 N.Y.S.2d 350, 355 (N.Y.App.Div.2001) (reasoning that where an expert explained the standard of care, and other evidence established that the defendant did not comply with that standard, the jury had all the information it needed to make a finding of breach); Ewing v. Alexander, 93 Mich.App. 179, 285 N.W.2d 808, 812 (1979) (reasoning that a malpractice plaintiff's expert witness need not expressly testify that the defendant violated the applicable standard of care, so long as the witness provides enough information to justify that inference by a fact-finder). [40] From Dr. Pennanen's (anticipated) testimony, the jury could also have found that the diagnostic delay at the front end of the January-to-June 2003 period when Coulter was under Dr. Fullum's care was a substantial factor that led to, and thus was proximate cause of, Coulter's worsened prognosis. Cf. Ferrell, 691 A.2d at 652 (concluding that where the evidence demonstrated that the claimed negligence was a substantial factor in the loss of [patient's] best chance for survival, the trial court's conclusion that [plaintiff] did not make a prima facie showing of proximate cause was erroneous). For these reasons, we conclude that, had the trial court been adequately apprised of the discovery record, it would not have been justified in precluding Dr. Pennanen from testifying, and it should not have directed a verdict in favor of Dr. Fullum. We emphasize that our analysis has focused on whether Coulter, permitted to call Dr. Pennanen to give testimony of a piece with her deposition testimony, Weiner, 557 A.2d at 1310, could have established prima facie that Dr. Fullum breached the standard of care in scheduling her mammogram and that this breach resulted in damages (not caused by extenuating circumstance attributable to Coulter). We have not discussed whether Dr. Pennanen's testimony could have enabled Coulter to establish that Dr. Fullum breached the standard of care in scheduling Coulter's mastectomy after he had obtained the mammogram and biopsy results. Dr. Fullum testified at trial (and Coulter acknowledged at her deposition) that one reason for delay between the biopsy results and the surgery was Coulter's having been very upset upon hearing the results, needing time ... to come to grips with the diagnosis, and not being in a position, at that particular time, to make any decisions regarding her care. Dr. Fullum explained that another reason for delay was that he wanted Coulter to obtain a second opinion before undergoing surgery and to have a metastatic workup to detect any spread of cancer to the liver, spleen, lungs or bones. Whether the delay in scheduling the surgery in order to obtain a second opinion and metastatic workup was consistent with the standard of care is an issue that calls for professional judgment. The record provides no indication of what Dr. Pennanen would have said about either reason for delay. Possibly, she might have clarified that the one-month between biopsy and mastectomy that she specified as the outside limit (absent extenuating circumstances) already took into account the time required for both. But, again, the record on this point seems inadequate. Thus, we do not suggest that Coulter would have been able to establish a prima facie case that Dr. Fullum breached the standard of care with respect to scheduling the surgery, in the absence of explicit testimony to the effect that delay for a metastatic workup and second opinion, under the circumstances here, amounted to such a breach. The point of our lengthy foregoing analysis, however, is that Coulter might have been able to show that the delay in obtaining the mammogram (and subsequent biopsy) so delayed the surgery that even if Fullum had operated forthwith after the biopsy, the damage was already done. Dr. Pennanen testified in her deposition that Coulter had fewer lymph nodes involved in the first one to two months of the January-to-June 2003 period, meaning, as we understand her testimony, that surgery by the end of March would likely have resulted in a much more favorable prognosis. So, even if Coulter did not have expert testimony to show damages from Dr. Fullum's post-biopsy conduct, it was possible that she still could make out a prima facie case of medical malpractice, on the ground that the front-end delay was the proximate cause of her injury. This does not end the matter, as we still must deal with the fact that Coulter's counsel  though asked repeatedly by the court to point to the relevant portions of Dr. Pennanen's deposition transcript  did not point the court to all of the portions that we have summarized or quoted above. Thus, at least arguably, Coulter invited the error of which she complains. We conclude that Coulter's failure to apprise the court fully about the content of Dr. Pennanen's testimony should not foreclose correction of the error now. First, it is necessary to read, in context, several lengthy portions of Dr. Pennanen's deposition to capture the opinions she expressed about the standard of care, deviation from it, and causation. We are doubtful that the trial court would have been able fully to appreciate the significance of Dr. Pennanen's testimony by looking at a few short passages during the bench conference that led up to the directed verdict. [41] Second, Coulter's counsel did plead with the court to voir dire Dr. Pennanen or to read her whole deposition before ruling, and did attempt to explain to the court how he thought Coulter would be able to establish that Dr. Fullum deviated from the standard of care (an explanation that the court rejected as wrong as a matter of law). Finally, the record makes clear that there would have been no ambush in permitting Dr. Pennanen to testify. From Dr. Pennanen's testimony during the deposition and from the explanations that Coulter's counsel gave at the deposition, Dr. Fullum's counsel had been specifically advised of how Coulter planned to prove her case. [42] The following excerpt from the transcript of Dr. Pennanen's deposition demonstrates that this is so: Fullum's counsel: [Addressing Coulter's counsel] [A]re you planning to call this doctor as a standard of care witness at trial? Coulter's counsel: Yes. And I plan to ask the doctor what is the standard of care, which is to say given an ordinary circumstance where a surgeon in Dr. Fullum's position and rendering the kind of care that was given to Ms. Coulter, what amount of time is the standard of care ordinarily between presentation of the patient and the surgery? That is to say that there are no complications and no extraneous problems which caused an unusual delay. Fullum's counsel: Are you offering Dr. Pennanen to testify that Dr. Fullum violated the standard of care or are you simply calling her to express her opinion as to what the standard of care is? Coulter's counsel: Well, certainly I am calling her to express her opinion as to what the standard of care is, which I understand to be two months, given no extraneous circumstances which would cause it to take longer. And I think I can demonstrate that there were no such circumstances that would have caused them to take more than two months and I think I can demonstrate through extrinsic evidence what it was that caused them to take five months [italics added]. At that point, Fullum's counsel said, I guess I will be asking you some questions. Thus, although Dr. Fullum's counsel told Judge Combs Greene that Dr. Fullum would be ambush[ed] if Dr. Pennanen was permitted to testify regarding deviation from the standard of care, the foregoing excerpt shows that defense counsel had been advised of the testimony that was planned. We do not believe it is a fair result for Dr. Fullum to retain the benefit  Judge Combs Greene's reversal of her statement Let's call [Dr. Pennanen] in, and the resultant directed verdict before the close of Coulter's case  that was based in large part on Dr. Fullum's counsel's cry of ambush and his failure to retract that claim even after Coulter's counsel had explained again how he would use Dr. Pennanen's standard-of-care testimony. Therefore, we will order that the trial court vacate the directed verdict as to Dr. Fullum and afford Coulter a new trial on the medical malpractice allegations against him stated in her first Amended Complaint. [43]