Opinion ID: 197865
Heading Depth: 2
Heading Rank: 1

Heading: Liability for Medical Malpractice

Text: 13 The negligence alleged in this case is medical malpractice. Under Massachusetts tort law, a plaintiff in a medical malpractice suit bears the burden of proving by a preponderance of the evidence that a physician-patient relationship existed between the physician and the injured party, that the physician breached his or her duty of care, and that the breach was the proximate cause of the injury. See Blood v. Lea, 403 Mass. 430, 530 N.E.2d 344, 347 (1988); see also Poyser v. United States, 602 F.Supp. 436, 438 (D.Mass.1984); Berardi v. Menicks, 340 Mass. 396, 164 N.E.2d 544, 546 (1960). Generally, a plaintiff in a medical malpractice action may carry his or her burden of proof on the issues of negligence and causation only with the assistance of expert testimony. See Harlow v. Chin, 405 Mass. 697, 545 N.E.2d 602, 605 (Mass.1989) (expert testimony generally required to prove causation); Forlano v. Hughes, 393 Mass. 502, 471 N.E.2d 1315, 1319 (1984) (expert medical opinion generally required to prove breach of duty of care). A physician is held to the standard of care and skill of the average practitioner of the medical specialty in question, taking into account the advances in the profession. See Poyser, 602 F.Supp. at 438-39 (citing Brune v. Belinkoff, 354 Mass. 102, 235 N.E.2d 793, 798 (1968)). Proof of the element of causation, which is an issue of fact, depends on whether it is more probable than not that the death was the result of the physician's negligence. See Harlow, 545 N.E.2d at 605. Here it must be emphasized that: 14 [w]hile the plaintiff is not bound to exclude every other possibility of cause for his injury except that of the negligence of the defendant, he is required to show by evidence a greater likelihood that it came from an act of negligence for which the defendant is responsible than from a cause for which the defendant is not liable. 15 Forlano, 471 N.E.2d at 1319 (citations omitted). 16 The defendant argues that the district court erred as a matter of law by evaluating its actions under a strict liability rather than negligence standard of care. The United States points to certain isolated statements made by the trial judge during trial that, it claims, establish that he applied a strict liability standard of care. We disagree. The comments in question were vague and do not necessarily establish that the judge applied the wrong standard of care. Indeed, in his findings of fact and conclusions of law, the trial judge relied on expert medical opinion in determining that Mr. Hassey's treating physicians provided negligent medical care, and that their negligence was a proximate cause of his death.
17 The United States complains that the district court erred in refusing to admit or consider the testimony of one of its medical experts on the statistics concerning the risk of stroke versus the risk of bleeding. We reject this assignment of error. The trial judge ultimately did not refuse to admit this testimony. Although he did, at first, resist the admission of the statistical evidence, on the following day the trial judge proceeded to hear the testimony in question. The defendant's invitation to reverse the judgment below is thus based on its speculative conclusion that the absence of a discussion of statistical evidence in the judge's findings of fact clearly indicate[s] that he did not consider this evidence because he was biased against its use. We decline the invitation to engage in such speculation.
18 The United States also claims that the judgment below must be reversed insofar as it rested on the plaintiff's expert testimony, which it contends should have been excluded by the district court under Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993). We reject this argument, too. The baseline for approaching questions of the admissibility of evidence is Fed.R.Evid. 402, which provides that [a]ll relevant evidence is admissible, except as otherwise provided by the Constitution, laws, or rules of the court. Evidence is relevant if it has any tendency to make the existence of any fact that is of consequence to the determination of the action more probable or less probable than it would be without the evidence. Fed.R.Evid. 401. As the Supreme Court noted, the Rule's basic standard of relevance thus is a liberal one. Daubert, 509 U.S. at 587, 113 S.Ct. at 2793-94. 19 With regard to expert testimony, the rules of evidence specifically provide: 20 If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise. 21 Fed.R.Evid. 702. In Daubert, which interpreted Rule 702, the Supreme Court held that when a trial judge is faced with the decision to accept or reject a proffer of expert scientific testimony, the judge must determine: 22 whether the expert is proposing to testify to (1) scientific knowledge that (2) will assist the trier of fact to understand or determine a fact in issue. This entails a preliminary assessment of whether the reasoning or methodology underlying the testimony is scientifically valid and of whether that reasoning and methodology properly can be applied to the facts in issue. 23 Daubert, 509 U.S. at 592-93, 113 S.Ct. at 2796; see also Vadala v. Teledyne Indus., Inc., 44 F.3d 36, 39 (1st Cir.1995). Of course, there is a third, implicit consideration: [t]he trial court first must determine whether the putative expert is qualified by knowledge, skill, experience, training, or education. See Ed Peters Jewelry Co., Inc. v. C & J Jewelry Co., Inc., 124 F.3d 252, 259 (1st Cir.1997) (quoting Bogosian v. Mercedes-Benz of N. Am., Inc., 104 F.3d 472, 476 (1st Cir.1997)); cf. Rohde v. Lawrence General Hosp., 34 Mass.App.Ct. 584, 614 N.E.2d 686, 688 (1993). Finally, we note that a district court enjoys substantial discretion to decide whether to admit or exclude relevant expert testimony. See General Elec. Co., 522 U.S. 136, 118 S.Ct. 512; Bogosian, 104 F.3d at 479. 24 There is no dispute over the professional qualifications of the plaintiff's expert witnesses, Drs. Barry Singer and Howard Adler. The first issue is thus whether the testimony offered by the plaintiff's expert witnesses was relevant--i.e., whether the testimony could assist the trier of fact to understand or determine a fact in issue. Daubert, 509 U.S. at 592, 113 S.Ct. at 2796. The issue before the judge was whether Mr. Hassey's treating physicians acted according to the standard of care and skill of the average member of a practitioner of their medical specialty, taking into account the advances in the profession, when they adjusted Mr. Hassey's anticoagulant levels before and after the colonoscopy. 25 The experts for both parties testified that during a colonoscopy, if a polyp is detected, the surgeon normally performs a polypectomy (a type of biopsy), cutting off the polyp for examination. The experts also agreed that anticoagulants can increase the risk of bleeding from wounds and retard their healing. Thus, to allow the clotting factors of a colonoscopy patient on Coumadin therapy to return to normal so as to permit adequate healing of his or her intestinal tissue, such a patient is required to be off Coumadin for a period of time. The longer the period during which the patient is not taking Coumadin, however, the greater the risk that he or she will suffer a stroke. The proper length of time to keep a colonoscopy patient off Coumadin therefore depends on a balancing between the risk of bleeding and the risk of stroke. 26 The testimony offered by Drs. Singer and Adler was certainly relevant to the issue at trial. Dr. Singer, an internist with specialties in hematology and oncology, testified that he had substantial experience in the use of Coumadin, and that he had performed several colonoscopies earlier in his career. He also testified that he had been consulted over 100 times by gastroenterologists seeking advice on the proper treatment for patients on anticoagulant medication who were scheduled to undergo colonoscopies. Similarly, Dr. Adler, an internist with a specialty in gastroenterology, testified that he has performed at least twenty thousand colonoscopies, as well as numerous biopsies, including polypectomies. He further testified that he was familiar with the risk of bleeding associated with these procedures, and with the standard of care expected of gastroenterologists in adjusting anticoagulant levels for patients undergoing colonoscopies. We find no error in the district judge's determination that the testimony provided by both of these experts would assist him in understanding and determining the facts at issue in this case. 27 Nevertheless, the United States challenges the admissibility of the opinions of these experts on the basis that such testimony was not reliable. With regard to Dr. Singer, the defendant claims that he was not qualified to testify about the defendants' treatment of Mr. Hassey because he is not a specialist in gastroenterology, and that he could not provide a reliable opinion on the risk of stroke as compared to the risk of bleed because he admitted during trial that he had no direct knowledge of the risk of bleeding from a colonoscopy during which a polypectomy was performed. 28 We disagree. First of all, the Government is simply wrong to suggest that Dr. Singer was not qualified to testify merely because he was not a gastroenterologist. The fact that the physician is not a specialist in the field in which he is giving his opinion affects not the admissibility of his opinion but the weight the jury may place on it. Payton v. Abbott Labs, 780 F.2d 147, 155 (1st Cir.1985); cf. Letch v. Daniels, 401 Mass. 65, 514 N.E.2d 675, 677 (1987) (A medical expert need not be a specialist in the area concerned nor be practicing in the same field as the defendant.) 29 Moreover, the specific testimony offered by Dr. Singer was within his area of expertise. He testified that cardiologists and hematologists are very much aware of the relative benefits and risks arising from the use of anticoagulants such as Coumadin, and the effects of their discontinuation. Dr. Singer explained that when a patient who has been taking Coumadin for several years is taken off the medication, that patient will enter a hypercoagulative state in which the rate at which clots are produced is greatly increased. Dr. Singer also testified that Coumadin takes about three days after it is restarted to have any effect on clot formation. Furthermore, Dr. Singer noted that he was familiar with the standard of care for gastroenterologists because he had been consulted by gastroenterologists on more than 100 occasions on the appropriate treatment for colonoscopy patients who are on anticoagulant therapy. 30 The United States makes much of the fact that Dr. Singer admitted that he did not know how the risk of bleeding would vary depending on whether a hot or cold biopsy had been performed. As other witnesses explained, biopsies can be cold or hot, the main difference being that during hot biopsies, the flesh is cauterized afterwards to minimize bleeding immediately after the operation. Patients undergoing hot biopsies, however, are at risk for delayed bleeding between seven and fourteen days after the operation, when the scab that formed over the cauterized tissue falls away. The defendant argues that Dr. Singer's admission establishes that his opinion--that the risk of bleeding was less than the risk of stroke--was personal speculation unsupported by any knowledge, training or experience and thus lacked a reliable factual foundation. 31 The inference is unwarranted. A review of the trial transcript indicates that Dr. Singer merely stated that he could not quantify the risk of bleeding from a biopsy. In the context of the question, risk referred to the likelihood of bleeding, not its severity. Dr. Singer also testified, however, that he knew that the risk of bleeding was generally lower than the risk of stroke in terms of severity because only a tiny fraction of patients undergoing biopsies die as a result of these procedures. In his opinion, the danger posed by keeping a patient off Coumadin for 11 days, with the attendant increase in the rate of clot production, is a greatly increased risk that the patient will suffer a stroke, which often leads to brain damage and death. It was not necessary for Dr. Singer to be able to specify in numerical terms the likelihood that a biopsy patient would bleed after an operation in order to support his opinion that the risk that a patient would suffer a stroke clearly exceeded the danger posed by the possibility of post-operative bleeding, and thus that anticoagulants should be restarted sooner than the defendants did with Mr. Hassey. 32 The United States also objects to Dr. Adler's testimony, which it also claims was unreliable and therefore should have been excluded under Daubert. Dr. Adler testified that he would have restarted anticoagulant therapy several days before Mr. Hassey's physicians did. The defendant's main complaint is that Dr. Adler rendered his opinion without first reading the transcripts of the physicians' depositions or certain parts of the medical record, including the post-operative report prepared by Dr. Berg. This complaint would be valid only if the parts of the record that Dr. Adler did not read contained information that was unavailable in the parts that he did read. In fact, Dr. Adler's evaluation of the pathologist's report allowed him to study the nature of the incisions made by the defendants in the course of the biopsy. This report is at least as reliable a basis for his opinion as the report prepared by the treating physicians. 33 The defendant also argues that there was a discrepancy between the treatment that Drs. Adler and Singer would have recommended for Mr. Hassey. We fail to see how this discrepancy should render Dr. Adler's testimony inadmissible. 2 To the contrary, although couched in Daubert terms, this argument is a thinly veiled challenge to the district court's determination of the credibility and soundness of Dr. Adler's opinion. The fact that defendant was able to undercut some of the research basis for the doctors' opinions does not affect the admissibility of those opinions. If the factual underpinnings of their opinions were in fact weak, that was a matter affecting the weight and credibility of their testimony. Payton, 780 F.2d at 156 (citing Coleman v. DeMinico, 730 F.2d 42, 47 (1st Cir.1984)); cf. Baker v. Commercial Union Ins. Co., 382 Mass. 347, 416 N.E.2d 187, 190 (1981) (The question whether the basis of the doctor's opinion is sound goes to the weight of the evidence, not its admissibility.) The finder of fact's determinations of credibility, and of the weight of the evidence in general, are not disturbed on appeal except for clear error. A finding of fact is clearly erroneous when the reviewing court is left with the definite and firm conviction that a mistake has been made. See Anderson v. City of Bessemer City, 470 U.S. 564, 573, 105 S.Ct. 1504, 1511, 84 L.Ed.2d 518 (1985). Thus, a credibility determination is clearly erroneous only when it is based on testimony that was inherently implausible, internally inconsistent, or critically impeached. See Keller v. United States, 38 F.3d 16, 25 (1st Cir.1994). 34 Dr. Adler's testimony was admissible and the court was entitled to rely on it: it was plainly plausible, internally consistent (it was partly inconsistent with Dr. Singer's testimony, not with his own), and was not critically impeached. More generally, the parties presented conflicting expert testimony from medical specialists on the issue of whether the defendants' decision to keep Mr. Hassey off Coumadin for more than ten days was a breach of the applicable standard of medical care and the proximate cause of his death. After reviewing the record below, including the transcripts of the trial, we find the evidence before the district judge to be sufficient to permit him to find that Drs. Berg, Van Dam, and Silver were negligent in their treatment of Mr. Hassey, and that their negligence was a proximate cause of his death.
35 The United States argues that a new trial was required because the plaintiff failed to provide any credible evidence that the risk of stroke was greater than the risk of bleeding, or that Mr. Hassey would not have had a stroke had the Coumadin therapy been restarted earlier. We disagree, for reasons already amply explored above.
36 Plaintiff's counsel filed a motion requesting certain conclusions of law, including a suggested award of damages. The United States argues that since the claim was for pain, suffering, and related subjective damages, the suggestion was a direct violation of Massachusetts law, which allegedly prohibits counsel from requesting that a finder of fact enter a specific subjective amount for unliquidated damage claims. 37 The request for mistrial was properly denied. First, a claim under section 2 of the wrongful death statute includes compensation not only for unliquidated damage claims, but also for liquidated damage claims, such as loss of income, which are not subject to the alleged prohibition. 3 Furthermore, the prohibition on suggestions as to the amount of awards for unliquidated damage claims is not a true prohibition, but rather only a strong recommendation. See, e.g., Goldstein v. Gontarz, 364 Mass. 800, 309 N.E.2d 196, 207 n. 15 (1974) (We agree with recent suggestions that in most cases where the damages are unliquidated and rest with the jury, the trial judge would be better advised to withhold the ad damnum from the jury than to read the figure and then attempt to negate its effect with an instruction.) (emphasis added). Moreover, a review of the relevant case law indicates this rule has only been applied to jury trials. In addition to the lack of precedent, we see no reason why Massachusetts would choose to extend the rule to bench trials, particularly since judges, unlike juries, are expected to be able to avoid being unduly influenced by counsel. Here, not only was the trial a bench trial, but it was the trial judge himself who requested an estimate of the amount of damages that should be awarded.
38 In September of 1996, an article was published in the Journal of Gastrointestinal Endoscopy which contained the results of a nationwide survey of gastroenterologists to determine the average standard of practice with respect to the management of antiplatelet agents and anticoagulants, including Coumadin, when performing diagnostic and therapeutic endoscopic procedures, including colonoscopies. See C.E. Angueira, et al., Gastrointestinal Endoscopy in Patients Taking Antiplatelet Agents and Anticoagulants: Survey of ASGE Members, 44 J. of Gastrointestinal Endoscopy, No. 3, at 309 (1996). The following month, the Government filed a motion under Fed.R.Civ.P. 60(b)(2) for relief from judgment, claiming that the article constituted new evidence that directly contradicted the district court's findings of fact and conclusions of law. The district court denied the motion, and the United States now argues that the denial was an abuse of discretion. 39 A motion under Rule 60(b)(2) for new trial on the ground of newly discovered evidence requires proof of the following elements: 40
41 (2) The evidence could not by due diligence have been discovered earlier by the movant[;] 42 (3) The evidence is not merely cumulative or impeaching; and 43 (4) The evidence is of such nature that it would probably change the result if a new trial is granted. 44 Raymond v. Raymond Corp., 938 F.2d 1518, 1527 (1st Cir.1991) (quoting Nickerson v. G.D. Searle & Co., 900 F.2d 412, 417 (1st Cir.1990)). A district court's ruling on a motion under Rule 60(b) will only be overturned for an abuse of discretion. See Raymond, 938 F.2d at 1527; Nickerson, 900 F.2d at 416; Duffy v. Clippinger, 857 F.2d 877, 879 (1st Cir.1988). 45 There are two problems with the defendant's argument. The first is that it is by no means clear that this article constitutes newly discovered evidence for purposes of Fed.R.Civ.P. 60(b). Although the trial was held on May 1-3, 1996, approximately four months before the article was published, an abstract of the article had been available since 1993. A more diligent effort to research the relevant medical literature by the defendant should have produced the abstract. 46 The second and more important problem is that the evidence would not be likely to change the result of the trial. The United States has retained as experts some of the authors of the article, one of whom would testify that, based on the survey, he thought that 60% of the gastroenterologists in the United States would have restarted Coumadin after a colonoscopy within 7 days or less. The proposed expert would also testify that there are no published guidelines at present that would assist endoscopists in managing patients on anticoagulant therapy during the period of time following a colonoscopy, and that most endoscopists are therefore using their own judgment or criteria in managing such patients. 47 This evidence would not have required the trial judge to reach a different result. As a general matter, the article, and the expert's testimony, are based on a survey to which only 38.5% of ASGE members responded, a response rate which was described by the authors of the article as less than ideal. Moreover, the responses were based on generalized questions, such as the length of time the gastroenterologists would wait before restarting Coumadin after a therapeutic colonoscopy (i.e., one during which a biopsy or polypectomy was performed) in patients suffering from conditions such as atrial fibrillation. The answers to these questions are not definitive because they did not take into consideration the particulars of a patient's medical history, even though the experts testifying before the trial judge agreed that such particulars are indispensable in determining the proper treatment to be followed. As for the proposed testimony regarding the lack of published guidelines, the fact remains that gastroenterologists cannot close their eyes to the standard of care appropriate to other specialties when performing procedures within their own that impact upon other specialties. 48 The trial judge heard testimony from specialists in hematology and gastroenterology who indicated that Mr. Hassey should not have been kept off Coumadin as long as he was, and explained in detail why they thought so. We think it improbable that the proposed evidence would have resulted in a different outcome.