Opinion ID: 220774
Heading Depth: 4
Heading Rank: 3

Heading: Testimony of Dr. Steven Alexander

Text: Like Dr. Wong, Dr. Steven Alexander was prepared to testify that to a reasonable degree of medical certainty, the cause of Huerta’s kidney rejection was inadequate immunosuppression resulting from “a preparation of [t]acrolimus that was insufficient.” R., Vol. I at 130. The district court held that Dr. Alexander’s testimony was unreliable because it was based on the erroneous assumption that Blanca’s tacrolimus suspension was subpotent even though that had not yet been established, Aug. 13, 2010 Op. at 11; R., Vol. I at 74, and because it was not based on any known facts. The district court found that Dr. Alexander’s differential diagnosis fell short of reliability. For example, Dr. Alexander testified that almost nothing would cause Huerta’s creatnine level to go from 0.6 to 9 except nonadherence. Id. at 80 (testifying that of the six different suspected explanations for creatinine levels spiking in kidney transplant patients when they have been stable for two years, nonadherence is considered numbers one, two, and three). Yet, Dr. Alexander ruled out “non-adherence” based on “knowing” Huerta’s family. Id. at 87, 90. Dr. Alexander, however, was not aware that following Huerta’s 2007 kidney rejection, “one of the concerns was that multiple family members were providing Blanca with her oral medications, and that they were concerned -15- she wasn’t being dosed sufficiently.” Id. at 88.5 When Dr. Alexander was informed that Huerta’s treating physicians suspected non-compliance as a cause of her 2007 kidney rejection, he maintained that compliance was not an issue in the May 2006 rejection because he “ha[d] no reason to doubt that [Huerta’s] mother was giving her her medications.” Id. at 90. The district court’s finding this to fall short of reliable testimony was not an abuse of discretion because Dr. Alexander did not “provide reasons for rejecting alternative hypotheses ‘using scientific methods and procedures.’” Clausen v. M/V NEW CARISSA, 339 F.3d 1049, 1058 (9th Cir. 2003) (quoting Claar v. Burlington N. R.R. Co., 29 F.3d 499, 502 (9th Cir.1994)). Dr. Alexander’s ruling out of non-adherence in view of contradictory evidence should have been “founded on more than ‘subjective beliefs or unsupported speculation.’” Id. (same). Although “‘[t]rained experts commonly extrapolate from existing data[,] . . . nothing . . . requires a district court to admit opinion evidence which is connected to existing data only by the ipse dixit of the expert. ’” Mitchell, 165 F.3d at 782 (quoting Joiner, 522 U.S. at 146). 5 In her reply brief, Huerta argues for the first time that the district court could not properly consider her May 2007 rejection as evidence of whether she took her medicine as prescribed in the time leading to her May 2006 rejection. Reply Br. 13. Huerta argues that this was “wholly irrelevant, constitute[d] improper character evidence, [was] more prejudicial than probative,” and was reversible error. Id. (citing Fed. R. Evid. 402, 403, and 404). By not raising this issue in her opening brief, however, Huerta has forfeited her right to appellate review of it. See Bronson v. Swensen, 500 F.3d 1099, 1104 (10th Cir. 2007) (explaining that “the omission of an issue in an opening brief generally forfeits appellate consideration of that issue”). -16- Dr. Alexander’s belief that he had no reason to doubt that Huerta was being dosed properly despite squarely contradictory evidence indicates that the district court was within its discretion to find his testimony unreliable. As our court has previously stated, “‘scientists whose conviction about the ultimate conclusion of their research is so firm that they are willing to aver under oath that it is correct prior to performing the necessary validating tests [may] properly be viewed by the district court as lacking the objectivity that is the hallmark of the scientific method.’” Id. at 783 (quoting Claar, 29 F.3d at 503). The district court also found that Dr. Alexander relied at least in part on Huerta’s attorneys’ representations that the tacrolimus suspension was subpotent. The district court found that this rendered his methodology unreliable because it was “derived from erroneous facts or assumptions.” Aug. 13, 2010 Op. at 11. We find that the district court was acting within its discretion in excluding Dr. Alexander’s testimony on this ground. C.f. In re Paoli R.R. Yard PCB Litig., 35 F.3d 717, 762 (3d Cir. 1994) (“We do not doubt the propriety of a medical report prepared just for litigation, but a physician who evaluates a patient in preparation for litigation should seek more than a patient’s selfreport of symptoms or illness . . . in order to determine that a patient is ill and what illness the patient has contracted.”). Huerta argues that Dr. Alexander’s testimony was based on his experience with other children who had undetectable levels of tacrolimus even though they were very compliant. Huerta also argues that Dr. Alexander based his testimony on his observations that Huerta had shown no prior problems and that her age group was the best in terms of -17- compliance. Moreover, Dr. Alexander also observed that improper compounding rather than improper dosing caused problems similar to those experienced by Huerta in children who took liquid tacrolimus. Even taking all of these observations as true for the sake of argument, however, we do not find that the district court abused its discretion. The district court was concerned with Dr. Alexander’s own characterization of non-adherence as comprising the top three of six explanations6 for severe kidney rejections in previouslystable patients, and then his summary rejection of “non-adherence” as a cause of Huerta’s kidney rejection in the face of contradictory evidence. Aug. 13, 2010 Op. at 8, 11-13. It was within the district court’s discretion to find Dr. Alexander’s testimony unreliable for this reason. See Bitler, 391 F.3d at 1124 (“[A]n inference to the best explanation for the cause of an accident must eliminate other possible sources as highly improbable, and must demonstrate that the cause identified is highly probable.”); see also Kumho Tire, 526 U.S. at 152.