Opinion ID: 2084511
Heading Depth: 1
Heading Rank: 4

Heading: Sufficiency of the Evidence and the Applicable Legal Standard

Text: The first issues raised by Ms. Drevenak pertain to the trial court's evaluation of the sufficiency of the evidence, particularly its assessment of the testimony presented by the experts. Noting that the trial court characterized the case as a battle of experts, Ms. Drevenak asserts that: [T]he trial court admitted that the published scientifically reliable evidence favored [Ms. Drevenak], but nonetheless gave greater weight to the defense experts whose testimony was not well supported by scientific evidence. [29] Moreover, she argues, the trial court did not weight the scientific validity of the testimony using the national standard of care or other tests of scientific reliability to assist in determining the reliability of the competing evidence. She also maintains that the scientific evidence adduced by [Dr. Abendschein's] witnesses was lacking in acceptance in the medical community and [suffered from] the lack of reliability of the opinions rendered. Furthermore, she faults the trial court for failing to evaluate the defense expert testimony under the standards announced in Frye or Daubert, supra . Although she recognizes that Frye, supra, addresses the admissibility of expert testimony (emphasis supplied in original), she contends that the [ Frye standard] should be used by a trial court sitting without a jury in evaluating expert testimony. In essence, Dr. Abendschein argues that the educational backgrounds and experience of his experts met the requirements of a national standard of care, as explained in Travers v. District of Columbia, 672 A.2d 566 (D.C.1996). He maintains that Travers does not require [r]eference to a published standard, if indeed one exists.... As Ms. Drevenak recognizes, the issue before us is not whether the testimony of defense experts was properly admitted into evidence by the trial judge. Rather, the issue is whether that evidence was sufficient to support the trial court's judgment. [30] This is a question of law, which we review de novo. See District of Columbia v. Wilson, 721 A.2d 591, 596 (D.C. 1998). Moreover, we `view[ ] the evidence in the light most favorable to the prevailing party....' Id. (quoting District of Columbia v. Cooper, 445 A.2d 652, 655 (D.C.1982) (en banc)). In Hawes v. Chua, 769 A.2d 797 (D.C. 2001), 2001 D.C.App. LEXIS 81, we examined this court's medical malpractice cases, including Travers and Wilson, supra, and identified at least seven legal principles [which] are important in assessing the sufficiency of national standard of care proof[:] First, the standard of care focuses on the course of action that a reasonably prudent doctor with the defendant's specialty would have taken under the same or similar circumstances. Meek [ v. Shepard, ] 484 A.2d [579], 581 [ (D.C. 1984)]. Second, the course of action or treatment must be followed nationally. Travers, supra, 672 A.2d at 568; see also Morrison v. MacNamara, 407 A.2d 555, 565 (D.C.1979). Third, the fact that District physicians follow a national standard of care is insufficient in and of itself to establish a national standard of care. Travers, supra, 672 A.2d at 569. Fourth, in demonstrating that a particular course of action or treatment is followed nationally, reference to a published standard is not required, but can be important. Id. at 568. Fifth, discussion of the course of action or treatment with doctors outside this jurisdiction, at seminars or conventions, who agree with it; or reference to specific medical literature may be sufficient. Id. at 569. Sixth, an expert's personal opinion does not constitute a statement of the national standard of care; thus a statement only of what the expert would do under similar circumstances ... is inadequate. Meek, supra, 484 A.2d at 581. Seventh, national standard of care testimony may not be based upon mere speculation or conjecture. Washington v. Washington Hosp. Ctr., 579 A.2d 177, 181 (D.C.1990). 769 A.2d at 806, 2001 D.C.App. LEXIS 81, at 21-22. Furthermore, as we reiterated in Bahura, supra: In general, although an opinion rises no higher than the level of the evidence and the logic on which it is predicated, it is for the jury, [in this case, the trial judge in a bench trial], with the assistance of vigorous cross-examination, to measure the worth of the opinion. Id. at 945 (quoting District of Columbia v. Bethel, 567 A.2d 1331, 1333 (D.C.1990) (citations omitted)). [31] We are also mindful of our view that: [E]xpert testimony is not binding on the trier of fact, Hughes v. Pender, 391 A.2d 259, 263-64 (D.C.1978), and the trier of fact is given considerable latitude in determining the weight to be given such evidence. Id. Therefore, an expert's testimony as to the standard of care does not conclusively establish the standard of care; it is only evidence of that standard. Waldman v. Levine, 544 A.2d 683, 689 (D.C.1988) (citation omitted). See also McLeish v. Beachy, 746 A.2d 892, 896 (D.C.2000) (distinguishing between the weight of testimony and its legal sufficiency); Richbow v. District of Columbia, 600 A.2d 1063, 1066 (D.C.1991) (Although an expert's testimony may not arbitrarily be disregarded or disbelieved, Rock Creek Plaza-Woodner Ltd. v. District of Columbia, 466 A.2d 857, 859 (D.C.1983), when there is some basis in the record for concluding that an expert witness should not be credited, we will not pit our judgment against that of the finder of fact who saw and heard the witness testify.). In light of this court's prior approach to sufficiency of the evidence challenges in medical malpractice cases, we first address Ms. Drevenak's argument that the [ Frye ] standard should be used by a trial court sitting without a jury in evaluating expert testimony. On the record before us, we decline to apply Frye to the sufficiency of the evidence issue. Frye and Daubert, supra, not only apply to the admissibility, [32] instead of the sufficiency, of evidence; but equally important, to novel scientific evidence or a novel scientific test or a unique controversial methodology or technique. See Ibn-Tamas v. United States, 455 A.2d 893, 895 (D.C.1983) (Gallagher, J., concurring) ( Frye requires the profferor of the expert on a new scientific theory to show that the evidence is not still in the experimental stage but has gained a scientific acceptance substantial enough to warrant the exercise of judicial discretion in favor of admissibility); Gilkey v. Schweitzer, 295 Mont. 345, 983 P.2d 869, 872 (1999) ( Daubert is limited to novel scientific evidence); Colwell v. Mentzer, 973 P.2d 631, 636 (Colo.App.1998) (Generally the test of Frye [, supra, ] is applied to novel scientific devices or processes involving the manipulation of physical evidence (citation omitted)). In contrast to Frye, supra, which concerned early consideration of the systolic blood pressure deception test, the forerunner of the polygraph test, and which is followed in this jurisdiction, Ms. Drevenak's case does not relate to any novel scientific evidence or test, nor to any unique, controversial methodology or technique. Rather, what is at issue in her case, primarily, is the exercise of clinical judgment based upon specialized medical knowledge. No question is presented here concerning the integrity of the knee prosthesis implanted in Ms. Drevenak's knee; nor is there any indication that the method of aspiration used to obtain cultures of the drainage from her knee was in the experimental stage at the time the aspirations were done. Therefore, we do not regard Ms. Drevenak's case as fitting the mold of one in which novel scientific evidence or a unique controversial methodology or technique is involved. In arguing for the applicability of the Frye principle to the sufficiency of the evidence, Ms. Drevenak's counsel expresses concern about determining the reliability of expert evidence. However, there are indicia of reliability other than sole reliance on the quantity of published scientific articles. Even Daubert, supra, as Ms. Drevenak acknowledges, identifies publication as only one factor in considering the admissibility of expert evidence, and Daubert specifically states that: publication... does not necessarily correlate with reliability. Id. at 593, 113 S.Ct. 2786 (citation omitted). Indeed, the following factors are all relevant to assessing the reliability of an expert's testimony in a medical malpractice action: the expert's training, board certification in the pertinent medical specialty, specialized medical experience, attendance at national seminars and meetings, familiarity with published specialized medical literature, and discussions with medical specialists from other geographical regions. Of these factors, the trial court obviously emphasized training, board certification in the pertinent medical specialty, and specialized medical experience, but did not ignore the expert's familiarity with published specialized medical literature. The trial judge credited the testimony of the defense experts, generally, because they were more qualified.... He explained that: [I]f you look at the collective experience of these experts, it's clear that the defense experts had many more years of practice and experience in the areas that they were talking about than [Ms. Drevenak's] expert[s]. And they also had a lot more experience in the number of cases that they'd seen over the course of their practice compared to [Ms. Drevenak's] expert[s]. The record on appeal supports the trial court's conclusions regarding the qualifications and experience of the experts. Dr. Smialowicz, Ms. Drevenak's infectious disease expert was not certified in internal medicine nor in infectious diseases. Thus there is a basis in the record for determining that his testimony should not be credited, see Richbow, supra, 600 A.2d at 1066, or that the testimony of the defense expert should be given greater weight. In contrast to Dr. Smialowicz, Dr. Mayrer, the defense expert in infectious diseases, who holds degrees from Columbia College and Yale Medical School, has taught at Yale, Johns Hopkins, and the University of Maryland, and serves as Attending Physician and Director of the Division of Infectious Diseases at Sinai Hospital of Baltimore, Maryland; is board certified both in internal medicine and infectious diseases. Furthermore, in comparison with Dr. Smialowicz who consults on at least two cases of prosthetic infection per year; over the past twenty years, Dr. Mayrer has consulted on one case of prosthetic infection per month, including hip (75 to 80 percent) and knee joint infection. The trial judge also noted that Dr. Mayrer had some publications in this area; his resume has an extensive listing of publications and presentations. Dr. Smialowicz' resume lists three publications, one of which concerns nursing. While Dr. Smialowicz' direct testimony referenced at least four works on infectious diseases, cross-examination revealed that during his deposition he had referenced only one article. Dr. Mayrer was subjected to vigorous cross-examination based on published works, including one by the chairman of his department at Johns Hopkins. He reflected familiarity, although not always total agreement, with these works, even indicating, in one case, that he had had breakfast with the author. Given the respective training, board certifications, experience, publications, and knowledge of the specialized literature, we see no reason to question the trial judge's decision to credit the testimony of Dr. Mayrer. The trial judge not only concluded that the defense experts addressed and articulated the national standard of care, but also effectively undermined or refuted Ms. Drevenak's experts' statement of the standard. We agree with Ms. Drevenak's counsel that: Bare assertions of the standard of care by an expert are inadequate. However, as the trial court concluded, the defense experts did more than articulate bare assertions. The trial judge found that ... Dr. Lewis was a qualified expert, and gave great weight to the fact that he'd done total knee replacements about two or three thousand times and that he gets referrals from other surgeons of their patients. And that in 25 years, he's seen about 125 to 150 infected total knee ... ruptured patellar tendons. Dr. Lewis graduated with high honors from Harvard Medical School, received training in Boston, the Washington Metropolitan area at NIH, and New York, was board certified in orthopedic surgery, is a charter member of the American Association of Hip and Knee Surgeons, has published works on orthopedic surgery in scientific journals, edited books, and for many years has known Dr. Lotke, the author of one of the texts used by Ms. Drevenak's experts. The trial judge also singled out the testimony of Dr. Grant, a graduate of Howard University College of Medicine, because of his role as director of the American Board of Orthopedic Surgeons, the body that constructs the test for other surgeons who are trying to achieve certification in orthopedic surgery. He also credited the fact that Dr. Grant has performed total knee replacements and has seen over the past 16 years several hundred infected knees. In addition, during his fellowship under one of the experts in the field, Dr. Thomas Mallory, Dr. Grant participated in over 600, 700 total joint replacements. In contrast to Doctors Lewis and Grant, Dr. Shall, Ms. Drevenak's standard of care expert, who earned his medical degree at the Medical College of Ohio at Toledo, and was board certified in orthopedic surgery, estimated on cross-examination that 5 percent of his experience concerned total knee replacement surgeries (which he stated, on direct examination, totaled 200). [33] Although Ms. Drevenak maintained, in a footnote in her brief, that: The record is replete with numerous ... instances of unsupported testimony by defendant's cadre of experts, in fact she singles out only one area of alleged error  that concerning the standard of care testimony with respect to aspiration of her knee to detect the presence of deep knee infection. Since there is no contention in this case that any of the defense expert testimony was inadmissible, including that pertaining to aspiration of Ms. Drevenak's knee, it was the trial judge's task in this bench trial to determine what weight, if any, to give the expert evidence. Ms. Drevenak's experts stressed early signs of deep knee infection, beginning in March and continuing into the subsequent months. These signs included drainage, redness, swelling, pain and elevated temperature, and Ms. Drevenak's experts maintained that the standard of care, as reflected in scientific publications, required the performance of an aspiration, and follow-up to determine the results of the aspiration. In addition, they opined that prescribing an oral antibiotic would only mask the signs of deep infection that caused the patellar ruptures, and ultimately, the loss of the prosthesis due to the synergistic interaction of two extremely virulent bacterial organisms. Dr. Abendschein's experts disagreed, explaining that symptoms such as redness, drainage and elevated temperature were to be expected in a post-operative patient, and at most, indicated superficial infection. They emphasized the absence of pus until July 1993, and opined that Ms. Drevenak would not have been able to engage in post-operative physical therapy had she suffered from a deep knee infection. [34] They attributed Ms. Drevenak's ruptured patellar tendon to trauma, that is, her sudden sitting down on March 26th and her April fall, both of which placed too much stress on her patellar tendon which already had been traumatized by her 1982 surgery, and the knee replacement surgery. In addition, the defense experts relied on a study by Dr. Harris in opining that an aspiration may be counter indicated because of the additional stress it places on the knee, and because its results may be misleading. Since there were no signs of virulent infection before July 1993, in their opinion, and because Ms. Drevenak suffered from other health problems requiring extensive medical attention, an aspiration was not appropriate in the absence of clear signs of deep knee infection, and in light of Dr. Abendschein's visual inspection of Ms. Drevenak's knee when he repaired both ruptures of her patellar tendon. Furthermore, Dr. Abendschein appropriately called in an infectious disease consultant, and both oral and intravenous antibiotics were used appropriately; an oral antibiotic could not have masked the symptoms of a virulent, aggressive deep knee infection. Clearly, this summary of the experts' testimony reveals that there was disagreement between Ms. Drevenak's experts and those testifying for Dr. Abendschein. The trial court's task, not ours, was to weigh this evidence. In this case the trial judge chose to give greater weight to the experts whose training, board certification in the pertinent medical specialty, and specialized medical experience, appeared to be more extensive, but who also reflected familiarity with and relied on published specialized medical literature. Based on the record before us, and viewing the evidence in the light most favorable to Ms. Drevenak, see Wilson, supra, we agree with Dr. Abendschein; the evidence was sufficient to support the trial court's findings and conclusions with regard to the aspiration of Ms. Drevenak's knee joint. We turn now to the factual issue relating to the presence of a sinus and sinus tract.