Opinion ID: 2279729
Heading Depth: 1
Heading Rank: 3

Heading: Alleged Negligence of Dr. Ammerman

Text: Cleary first sought information from Dr. Ammerman about the DREZ procedure in late 1983 after a referral physician mentioned it, and he and Dr. Ammerman discussed the procedure again in January 1984. At no time did Dr. Ammerman propose or recommend that Cleary undergo the procedure. There is no dispute that Dr. Ammerman had read the available published materials about the DREZ procedure prior to these consultations, and there is no dispute that Dr. Ammerman informed Cleary that he might benefit from the procedure and informed Cleary that there was a risk of resulting weakness or paralysis in his ipsolateral leg. Neither party disputes that information about risk of leg weakness or paralysis was material to Cleary because of Cleary's inability to use his injured arm to support himself with a cane. In short, if he could not walk without a cane, he probably would not be able to walk at all. Nor is there any dispute that the reason Cleary did not seek GHA's authorization for treatment with this procedure in 1984 was because he was concerned about that risk. The only factual disputes are whether Dr. Ammerman gave Cleary inaccurate information about the risks and benefits of the DREZ procedure, [2] and whether Dr. Ammerman should have known, at the last consult in January 1984, that the information was inaccurate, i.e., should have known that any leg weakness associated with the DREZ procedure was unlikely to render Cleary non-ambulatory. The trial court found that Cleary established a standard of care  that once a physician provides information to a patient, he has to provide accurate information. However, the trial court ruled that, assuming Dr. Ammerman's advice was inaccurate and assuming the information was material to Cleary, expert testimony was required to establish that the inaccuracy was so significant or of such magnitude that it deviated from the standard of care. The court also ruled that Cleary had not presented such testimony. To establish that Dr. Ammerman was negligent, Cleary presented Dr. Allan Friedman, the physician who performed the DREZ procedure on Cleary, as an expert. He testified that based on information available in the neurosurgery literature: a reasonably prudent physician treating a BPA patient in 1979 would be aware that the DREZ procedure existed; by 1984 it was well established that the procedure was efficacious and had a lower risk of complications than previously reported; and by 1984 it would be reasonable for a physician treating a BPA patient to discuss DREZ with the patient. Dr. Friedman testified, in terms of his own experience, that he always tells a DREZ patient about possible resulting weakness and numbness, but that he has had no DREZ patients who required a cane or walker. In addition, as the trial court recognized, there was evidence that the information provided to Cleary was not completely accurate: in response to a hypothetical posed by Cleary, Dr. Friedman testified that, in late 1983 or early 1984, it was not in keeping with what's in the literature to have advised a patient that he would likely become non-ambulatory if he had the DREZ procedure; and Dr. Ammerman and a GHA expert medical witness both conceded that there are no references in the medical literature to any DREZ patient becoming non-ambulatory or having a completely paralyzed ipsolateral leg. However, importantly, Dr. Friedman also testified that in January 1984 it was not unreasonable to tell a patient considering the DREZ procedure that a known complication might be resulting weakness in the ipsolateral leg. Significantly, too, Dr. Friedman expressly stated that he was not giving an opinion that Dr. Ammerman breached the standard of care, because he had never been provided with, or reviewed, Cleary's entire GHA file. Cleary presented no other expert testimony bearing on Dr. Ammerman's advice to Cleary. Generally, in a medical malpractice negligence action the plaintiff must present medical expert testimony to establish the standard of care, expert testimony that the defendant's conduct deviated from that standard of care, and expert testimony establishing that the alleged deviation proximately caused the plaintiff's injuries. See Travers v. District of Columbia, 672 A.2d 566, 568 (D.C. 1996); Washington v. Washington Hosp. Ctr., 579 A.2d 177, 181 (D.C.1990); Harris v. Cafritz Memorial Hosp., 364 A.2d 135, 137 (D.C.1976). Although there are cases which do not require expert testimony on the issue of breach, i.e., cases [w]here laymen can say, as a matter of common knowledge and observation, that the type of harm would not ordinarily occur in the absence of negligence, Harris, supra, 364 A.2d at 137, expert testimony is required if a case involves the merits and performance of scientific treatment, complex medical procedures, or the exercise of professional skill and judgment, [because] a jury will not be qualified to determine whether there was unskillful or negligent treatment without the aid of expert testimony. Id. (emphasis added); see also Washington Hosp. Ctr. v. Martin, 454 A.2d 306, 308 (D.C.1982). Cleary's claim that Dr. Ammerman was negligent hinges on whether Dr. Ammerman's interpretation of medical information available in neurosurgery journals was unreasonably inaccurate. Interpretation of medical literature, and the application of that interpretation to a particular patient's circumstances, is an exercise of medical judgment, and is not a subject within the ken of lay jurors. See Nimetz v. Cappadona, 596 A.2d 603, 606 (D.C.1991) (expert testimony is required when the subject presented is `so distinctly related to some science, profession, or occupation as to be beyond the ken of the average layperson') (quoting District of Columbia v. Peters, 527 A.2d 1269, 1273 (D.C.1987)); Canterbury v. Spence, 150 U.S.App. D.C. 263, 276-78, 464 F.2d 772, 785-87 (1972) (prevailing medical practice must be considered when medical judgment is at issue; ordinarily, only the physician is in a position to identify particular dangers); Festa v. Greenberg, 354 Pa.Super. 346, 511 A.2d 1371, 1378 (1986) (only a physician is qualified to determine whether a risk exists and the likelihood of occurrence). Cf. Washington Hosp. Ctr. v. Martin, supra, 454 A.2d at 308 (expert testimony not required where issue before jury is whether appellee was in fact under restraints immediately prior to her fall); Washington Hosp. Ctr. v. Butler, 127 U.S.App. D.C. 379, 385, 384 F.2d 331, 337 (1967) (expert testimony not required on issue of whether order for diagnostic test should have noted patient's dizziness when doctor had noted the symptom on patient's admission note). As is apparent, Dr. Friedman did not give the required opinion testimony on breach; indeed, appellant concedes as much in his reply brief. Therefore, unless there is some other theory that relieves Cleary of his burden to present expert testimony establishing that Dr. Ammerman breached the standard of care, his claim fails for the lack of such testimony. In response, Cleary contends that the principles of the informed consent doctrine should apply to his claim because the conduct alleged to be negligent concerns information conveyed from a physician to his patient. Thus, he argues, expert testimony was not necessary to establish breach because if the jurors were to determine that Dr. Ammerman had `overstated the risk in his conversation with Mr. Cleary,' then in light of the expert testimony presented at trial, they would have been able to determine whether that overstatement was a deviation from the standard of care. He further maintains that, under the informed consent doctrine, expert testimony is not required to establish a breach of the standard of care because the issue is whether a reasonable person in what the physician knows or should know to be the patient's position would consider the information material to his decision. See, e.g., Crain v. Allison, 443 A.2d 558, 562 (D.C.1982). Under the informed consent theory, the determination of materiality is a two-step process. First, expert testimony is required to establish the nature of the risks inherent in a particular treatment, the probabilities of therapeutic success, the frequency of the occurrence of particular risks, the nature of available alternatives to treatment and whether or not disclosure would be detrimental to a patient. Sard v. Hardy, 281 Md. 432, 379 A.2d 1014, 1024 (1977). Once the physician has ascertained the risks and alternatives, and has communicated this information to the patient, id., the second step is reached, where it is the patient's exclusive right to weigh these risks together with his individual subjective fears and hopes and to determine whether or not to place his body in the hands of the surgeon or physician. No question requiring the exercise of medical judgment ever arises at this stage of the decision-making process. Id. (citations omitted). See also Canterbury, supra, 150 U.S.App. D.C. at 282-83, 464 F.2d at 791-92 (experts are required to identify and elucidate the risks of therapy, but lay witnesses can competently establish failure to disclose risk information, a patient's lack of knowledge of the risk, and the adverse consequences following treatment); Cobbs v. Grant, 8 Cal.3d 229, 104 Cal.Rptr. 505, 513-14, 502 P.2d 1, 10 (1972); [3] Festa, supra, 511 A.2d at 1376-78. [4] The principles of informed consent do not apply to the circumstances presented here, however, because the allegations of negligence in this case do not turn on whether the risks disclosed by Dr. Ammerman were material  the parties agree that a risk of paralysis or weakness in the ipsolateral leg was important to Cleary, and that Dr. Ammerman knew that was so. Instead, the allegations of negligence center on the reasonableness of Dr. Ammerman's interpretation of the available medical literature, i.e., whether, in the exercise of ordinary care expected of a neurosurgeon treating a BPA patient, Dr. Ammerman should have been aware that the DREZ procedure was not likely to render Cleary non-ambulatory. Cf. Sard, supra, 379 A.2d at 1022-23 (where the physician does not know of a risk and should not have been aware of it in the exercise of ordinary care, he is under no obligation to make disclosure). As we have said, the reasonable interpretation of medical literature is not a subject within the ken of lay jurors. Furthermore, we agree with the trial court that the circumstances here are not sufficiently analogous to those found in informed consent cases so as to allow the application of informed consent principles. The physician here was not proposing a particular treatment for the patient to accept or reject, but discussing with the patient various possible courses of treatment. We think these circumstances are like those in the diagnosis and treatment medical malpractice cases. For example, in Wilkinson v. Vesey, 110 R.I. 606, 295 A.2d 676 (1972), ordinary medical negligence theory claims and an informed consent theory claim were at issue on appeal. Wilkinson claimed that the physicians incorrectly diagnosed her ailment, improperly administered treatment, and failed to obtain her knowing consent. Although the Wilkinson court held that expert testimony was not required on the informed consent claim to show the reasonableness or unreasonableness of the extent of a physician's communication with the patient, it also stated, on the diagnosis and treatment claims, that expert testimony was required to demonstrate any deviation from the standard of care. See id. 295 A.2d at 682. The factual issues in Wilkinson's diagnosis and treatment claims centered on the merits and performance of scientific treatment or the exercise of professional skill and judgment, and were much like the factual issues raised by Cleary: Did the physicians follow good practice protocol? Whose responsibility was it to make recommendations for treatment? Did the physicians fail to avail themselves of the scientific means and facilities available to obtain the best factual data? See id. at 682-85. See also Schenck v. Roger Williams Gen. Hosp., 119 R.I. 510, 382 A.2d 514 (1978) (negligent diagnosis claim included physician's failure to conduct a test, consult a report, or perform an examination, i.e., utilize the scientific advancements available to him). For this type of claim, expert testimony is required to show not only the standard of care, but also to demonstrate any deviation from that standard. See Allen v. Hill, 626 A.2d 875, 877 (D.C.1993); Washington v. Washington Hosp. Ctr., supra, 579 A.2d at 181 (expert testimony is usually required to establish each element of medical malpractice claim); Wilkinson, supra, 295 A.2d at 682. Moreover, in contrast to the issue in this case, informed consent claims concern a duty of the physician which is completely separate and distinct from his responsibility to skillfully diagnose and treat the patient's ills. Wilkinson, supra, 295 A.2d at 685. In order to prevail in an action based on a theory of informed consent, the plaintiff must prove that if he had been informed of the material risk, he would not have consented to the procedure and that he had been injured as a result of submitting to the procedure. Id. at 690; see also, e.g., Kelton v. District of Columbia, 413 A.2d 919, 922 (D.C. 1980) (a breach of duty to disclose ... is not actionable in negligence unless it induces the patient's uninformed consent to a risky operation from which damages actually result). The factual issues in an informed consent case revolve around materiality; those not requiring expert testimony typically ask a jury to determine whether an unrevealed risk materialized, whether the physician told the patient about that risk, and whether the physician should have known that knowledge of that risk might affect the patient's decision. See id. 295 A.2d at 688-89; see also Crain, supra, 443 A.2d at 563; Canterbury, supra, 150 U.S.App. D.C. at 277-79, 281, 464 F.2d at 786-88. As we have said, these are not the kind of factual issues raised by Cleary. Therefore, Cleary cannot invoke informed consent principles to bypass the requirement that he present an expert opinion that Dr. Ammerman breached his duty to give Cleary accurate information about the DREZ procedure. [5]