Opinion ID: 1421546
Heading Depth: 1
Heading Rank: 3

Heading: the contents of dr. fox' declaration

Text: (6a), (7a) The trial court also rejected Dr. Fox' declaration on the grounds that it lacked the requisite foundational facts to qualify him to testify about the standard of care and tended to shotgun his opinions in a conclusionary way. While we agree that Dr. Fox' declaration was conclusionary in a number of respects, the declaration contains several factual assertions establishing triable issues of fact and precluding its rejection. We also conclude that Dr. Fox was qualified to testify about the standard of care. Dr. Fox' summary of decedent's medical records outlining the treatment administered is not challenged but is reinforced by the defense showing. On November 1, 1977, decedent went to the UCLA radiology department as an outpatient for X-rays of her toes preparatory to surgery for rheumatoid arthritis of the joints of her toes. She fell and struck her head. A skull series was taken. She returned to the hospital in December, and the surgery was performed. On January 10, she was rehospitalized because of some infections in the incisional sites of the foot. The next day X-rays were taken including X-rays of the cervical spine. In September and October 1978, she was again in the hospital because of infection in her foot, and during this period she was treated for rheumatoid arthritis, dislocated hip, respiratory difficulties, and apparently she was given a pacemaker. She was removed to St. Joseph Hospital at the request of her family on November 9 where she was discharged on November 17. She returned to St. Joseph Hospital a week later, and she died March 26, 1979. An autopsy revealed that the cause of death was a fracture of the odontoid process with spinal cord damage. The motions for summary judgment of the defendant physicians, including the radiologists, and of Holly Hoberg, a radiology technician, were supported by the declarations of the moving parties, the declaration of D.M. Forrester, M.D., and portions of the deposition of George Campion, M.D. In addition, the motion of defendant Richard D. Ferkel, M.D., a general surgeon, was also supported by the declaration of Ronald W. Busuttil, M.D., board certified in general surgery; the motions of defendants Baldwin, Bernstein, Cooman, Cracchiolo, Galleno, Levensen, Purcell and Tibone, all orthopedic surgeons, were also supported by the declaration of Leonard Marmor, M.D., a board certified orthopedic surgeon; and the motions of defendants Barnett, Carlson, Cassan, Croft, Levy, Kovick, MacAlpin, Simmons, and Van Herle, whose specialties were rheumatology, internal medicine, respiratory care, cardiology, pulmonary diseases, and endocrinology, were also supported by the declaration of Matthew O. Locks, M.D., who is board certified in internal medicine. The declarations of the doctor defendants categorically denied the charging allegations of the complaint and declared, inter alia, their specific involvements in the case of Ada Crews Mann, that they were not in the room when she fell on November 1, 1977; that they had not at any time concealed, attempted, or conspired to conceal, any information from anyone regarding the health, care, and/or treatment of her; that services they provided for decedent were not provided for the purpose of artificially inflating her bill or obtaining Medicare or MediCal funds; that they never attempted or conspired to kill Ada Crews Mann, and that, in their opinion, their conduct at all times conformed to the standard of practice in the community relating to the practice of their named specialty. The declaration of Holly Hoberg declares that her only involvement with the decedent occurred when she and decedent were in an X-ray room on November 1, 1977; that she had never concealed or attempted or conspired to conceal any information from anyone regarding the health, care, and/or treatment of decedent; that the services she had provided to decedent were not for the purpose of inflating her bill or obtaining funds, and that she never attempted or conspired to kill decedent. An earlier affidavit of Hoberg had been filed in the court's records. It declared that her function at UCLA was to position patients so that X-rays could be taken and then to take X-rays; that she had been positioning Ada Crews Mann's feet for X-rays when she fell on November 1, 1977; and that the allegations of the complaint that Hoberg was a party to a conspiracy to conceal medical facts and that she kept decedent in a drugged state and attempted to kill her were sham, spurious, and scandalous. The declaration of D.M. Forrester, M.D., a board certified radiologist dated August 28, 1981, declared that she had reviewed copies of the X-rays of decedent taken after her fall on November 1, 1977, and copies of many other listed X-rays and of radiology reports, all of which had the name of Ada Crews Mann on them and were from UCLA. In her opinion, all of those reports were prepared in conformity with the standard of practice for radiologists in this community. She further states: To a reasonable degree of medical certainty the November 1, 1977 x-rays do not show any fracture or dislocation. To a reasonable degree of medical certainty I do not believe the patient sustained a fracture of the odontoid process on November 1, 1977 at any time that day prior to the taking of those x-rays. Some of the reasons for my opinion are: (1) The alignment of C-1 and C-2 is normal; (2) There is no evidence of prevertebral soft tissue swelling, which normally would be present if the patient sustained a fracture of the odontoid process; (3) If the patient had recently sustained a fracture of the odontoid process she would have been in too much pain to rotate her head to the positions required for that series of x-rays. George Campion, M.D., is director of radiology at St. Joseph Medical Center, Burbank, California. In his deposition, he stated in reference to the November 1 skull X-ray pictures of decedent Ada Crews Mann that ... you cannot anatomically rule it out [a fracture of the odontoid process] on radiographic method, although the fact that she can turn her neck for the positioning of the skull X/rays, it is unlikely that she does have a fracture at this time, and that, if her odontoid had been fractured on that date, ... I don't think the patient would have been able to turn her neck in order to position her head for these lateral views. Campion also stated that he had not formulated an opinion as to whether any of defendant Doctors Arndt, Bassett, Bein, Bennett, Bernstein, Bohman, Drake, Feigenbaum, Friedman, Gold, Levine, Manger, Morton, Russell, Scanlon, Schmidt and Weiner had failed to comply with the standard practice relating to radiology in relation to decedent Ada Crews Mann and that he had never told anyone that any of those doctors had failed to comply with the standard of practice. The declaration of Dr. Busuttil, supporting the motion of defendant Ferkel, declared that he had reviewed the UCLA Hospital and Clinic's chart pertaining to Ada Crews Mann. In his opinion, the care rendered to her by Richard Ferkel, M.D., conformed to the standard of practice relating to general surgeons in the community in the light of her history and symptoms. The declaration of Leonard Marmor, M.D., supporting the motions of the orthopedic surgeons declared that he had reviewed the UCLA Hospital and Clinic's chart relating to Ada Crews Mann and copies of numerous listed X-rays pertaining to her, including those of November 1. In his opinion the care rendered to decedent by the eight orthopedic surgeons conformed to the standard of practice for orthopedic surgeons in the community in the light of her history and symptoms. The declaration of Matthew O. Locks, M.D., supporting the motions of the remaining treating doctors, declared that he had reviewed a copy of the UCLA Hospital and Clinic report pertaining to Ada Crews Mann. Based upon his education, professional background, and review of the above-mentioned records, it was his opinion that the care rendered to Ada Crews Mann by each of those doctors, naming each of them, was appropriate and reasonable, in light of Ada Crews Mann's history and symptoms. The records reflected that she had a multitude of serious medical problems, including severe rheumatoid arthritis, and that the care and treatment rendered to decedent by those doctors conformed to the standard of practice in the community of internists. The declaration of defendant Bernard Strohm established that he was the associate director/administrator at UCLA Hospital and Clinics; that he had no contact with Ada Crews Mann and was not aware that she was a patient at UCLA until after the instant lawsuit was filed; and that he never concealed or attempted or conspired to conceal any information from anyone regarding the health, care, and/or treatment of Ada Crews Mann and had never attempted or conspired to kill her. The declaration of defendant William S. Russell established that he was the data processing manager at UCLA Hospital and Clinics during the relevant period of time. He had no contact with Ada Crews Mann and was not aware that she was a patient at UCLA until after the lawsuit was filed. He had never concealed or attempted or conspired to conceal any information concerning her health or care or medical treatment from anyone and had never attempted or conspired to kill her. Dr. Fox, plaintiffs' expert, a diplomate of the American Boards of Surgery and of Neurological Surgery, filed a declaration which incorporates his report and may be summarized as follows: A December 21, 1976, X-ray shows no fracture, dislocation, or subluxation of the odontoid. The lateral skull film of November 1, 1977, reveals fracture of the odontoid just below the skull line, and there is no open-mouth view to confirm it. There were no cervical spine films to compare. The X-ray report of November 1 is very sketchy and incomplete and states that the tape was broken. [7] The January 11, 1978, films confirm a fracture-dislocation of the odontoid process. The radiologist, Richard H. Gold, M.D., interpreted this as erosion of the dens secondary to rheumatoid disease. He recommended an open-mouth view, which was never taken, and tomography, which was never obtained. The medical records show repeated complaints of head and neck pain in 1977 and 1978. The September 4, 1978, films confirm the subluxation of C-1 and C-2 with posterior displacement, and this is confirmed by the radiology reports of the UCLA radiology department. Decedent was never treated for the fracture at the UCLA Medical Center. In Dr. Fox' opinion, after reviewing the medical records and X-rays, the treatment at the medical center was below the standard of practice. It was below the standard of practice not to discover the fracture and to fail to take cervical spine films on November 1, 1977. Because the earlier films showed no injury, it is reasonable to assume that the fracture occurred when decedent fell on November 1. Dr. Fox was critical of Dr. Forrester's declaration. Pointing to her statement that the alignment of C-1 and C-2 is normal, he points out that no films of the cervical spine were taken on November 1 and that the January 11 and September 4 films which were of the cervical spine show a fracture dislocation and subluxation of C-1 and C-2. Dr. Fox criticizes Dr. Forrester's reliance on the absence of prevertebral soft tissue swelling, stating that the patient did not have time to develop swelling because the films were taken immediately after the fall. Dr. Fox also criticizes the third reason offered by Dr. Forrester for concluding there was no fracture on November 1  if decedent had sustained a fracture the patient would have been in too much pain to rotate her head to the positions required for the skull X-rays. Dr. Fox states that decedent obviously did have the films and did not have to rotate her head to obtain laterals or AP's or Towne views, no rotation was needed! Dr. Fox also challenges the other nondefendant doctors who filed declarations that the defendant doctors conformed to the standard of practice. He asserts that in view of the history of head injury, the symptoms of neck pain reported in the nurse's notes, and respiratory distress, the orthopedic surgeons should have evaluated the patient's neck. Dr. Fox also asserts internal medicine specialists and other respiratory specialists, in view of the symptoms, should have been alert to cervical damage. Finally, he challenges the general surgeon's declaration, asserting that it is inappropriate for a general surgeon to determine the standard of care for arthritic specialists and a cardiologist. (8) The summary judgment procedure, inasmuch as it denies the right of the adverse party to a trial, is drastic and should be used with caution. ( Eagle Oil & Ref. Co. v. Prentice (1942) 19 Cal.2d 553, 556 [122 P.2d 264].) (9) Summary judgment is properly granted only when the evidence in support of the moving party establishes that there is no issue of fact to be tried. (Code Civ. Proc., § 437c; Lipson v. Superior Court (1982) 31 Cal.3d 362, 374 [182 Cal. Rptr. 629, 644 P.2d 822].) (10) The moving party bears the burden of furnishing supporting documents that establish that the claims of the adverse party are entirely without merit on any legal theory. ( Lipson v. Superior Court, supra, 31 Cal.3d at p. 374.) (11), (12) The affidavits of the moving party are strictly construed and those of his opponent liberally construed, and doubts as to the propriety of summary judgment should be resolved against granting the motion. ( Slobojan v. Western Travelers Life Ins. Co. (1969) 70 Cal.2d 432, 436-439 [74 Cal. Rptr. 895, 450 P.2d 271]. (13) ... [I]ssue finding rather than issue determination is the pivot upon which the summary judgment law turns. ( Walsh v. Walsh (1941) 18 Cal.2d 439, 441 [116 P.2d 62].) (14) The courts require only that physicians and surgeons exercise in diagnosis and treatment that reasonable degree of skill, knowledge, and care ordinarily possessed and exercised by members of the medical profession under similar circumstances. ( Bardessono v. Michels (1970) 3 Cal.3d 780, 788 [91 Cal. Rptr. 760, 478 P.2d 480, 45 A.L.R.3d 717].) (15) In deciding whether physicians and surgeons have met this standard, the trier of fact may infer failure of the practitioner to have done so in cases in which the happening of the accident does not normally occur in the absence of negligence. While other cases may require expert testimony to establish the standard of care, such cases do not. ( Id., at pp. 788-793.) (6b) The trier of fact may infer negligence from the factual statements of Dr. Fox. His declaration that the November 1 X-ray shows the fracture and the radiology report fails to show the fracture would warrant the trier of fact upon reviewing the X-rays to conclude that the radiologists were negligent in not observing what was apparent from the X-rays and taking appropriate action. [8] Moreover, Dr. Fox's declaration clearly undermines the factual basis for Dr. Forrester's declaration which forms the basis of the radiologists' motions for summary judgment. The trier of fact could also infer that in common X-ray procedures the patients do not fall in the absence of negligence and that when patients do fall, the person positioning the patient is probably the person responsible. In addition, according to Dr. Fox, the radiologist reports of January 11 and September 4 reflect a problem as to C-1 and C-2 and recommend further procedures. The recommended procedures were not done. A trier of fact without expert testimony as to the standard of care could infer that failure to follow the recommendations constituted negligence. An excuse for failure to follow the recommendations might require testimony as to the standard of care, but no excuse has been offered. Without expert testimony as to the standard of care, the trier of fact upon viewing the January 11 and September 4 X-rays in the light of Dr. Fox' declaration that they show the fracture could infer, depending upon their viewing of the X-rays, that the radiologists should have identified a fracture and were negligent in not observing it. Accordingly, entirely apart from his statements as to the standard of care, Dr. Fox' declaration contained factual assertions which if accepted would permit a finding of negligence and it was error for the trial court to reject his declaration on the grounds that it was conclusory. (7b) In any event, Dr. Fox was competent to testify as to the standard of care. (16) In Brown v. Colm (1974) 11 Cal.3d 639, 644 [114 Cal. Rptr. 128, 522 P.2d 688], we rejected an invariable rule which would require in all cases that an expert must have acquired a personal, working knowledge of the standard of care at the precise time when the alleged malpractice occurred. The court reasoned in part: While a layman may not testify to a fact which he has learned only by reading a medical book, there is no question that a professional physician may rely upon medical texts as the basis for his testimony. ( Healy v. Visalia etc. R.R. Co. (1894) 101 Cal. 585, 591-592 [36 P. 125]; Hope v. Arrowhead & Puritas Waters, Inc. (1959) 174 Cal. App.2d 222, 230 [344 P.2d 428]; Brown v. Los Angeles Transit Lines (1955) 135 Cal. App.2d 709, 716 et seq. [287 P.2d 810]; Forrest v. Fink (1925) 71 Cal. App. 34, 39-40 [234 P. 860].) Wigmore justifies the foregoing distinction by pointing out that a medical doctor possesses a professional experience which gives him a knowledge of the trustworthy authorities and the proper sources of information, as well as a degree of personal observation of the general subject enabling him to estimate the plausibility of the views expressed. Furthermore, he opines, it may be impossible to obtain information on the particular matter except through the reported data. (2 Wigmore on Evidence (1940) § 665b, pp. 784-785.) ... The unmistakable general trend in recent years has been toward liberalizing the rules relating to the testimonial qualifications of medical experts. Thus, whereas a number of earlier cases held that a physician of necessity must possess the skill ordinarily practiced only in the same locality (see, e.g., Trindle v. Wheeler (1943) 23 Cal.2d 330, 333 [143 P.2d 932]), only six years later this requirement was relaxed so that a physician was deemed qualified as an expert if he could testify to the practice in a similar community. ( Sinz v. Owens, supra, 33 Cal.2d 749, 756 [205 P.2d 3, 8 A.L.R.2d 757].) Some early cases were unbending in requiring expertise as to the precise injury involved in the litigation, as, e.g., not permitting an autopsy surgeon to testify on urology ( Moore v. Belt (1949) 34 Cal.2d 525 [212 P.2d 509]). Other authorities, however, have permitted variations, as, e.g., a pathologist was qualified to testify as to causes of aseptic necrosis ( Agnew v. City of Los Angeles (1950) 97 Cal. App.2d 557, 566 [218 P.2d 66]); an expert in otolaryngology to testify regarding plastic surgery ( Mirich v. Balsinger (1942) 53 Cal. App.2d 105 [127 P.2d 639]); a homeopathic physician and surgeon to testify on the degree of care required of a physician educated in the allopathic school of medicine ( Hutter v. Hommel (1931) 213 Cal. 677, 681 [3 P.2d 554]); a pathologist and professor of pathology to testify on the subject of gynecology ( Cline v. Lund, supra, 31 Cal. App.3d at p. 766). There are sound and persuasive reasons supporting this trend toward permitting admissibility more readily, rather than rigidly compelling rejection of expert testimony. It is obvious that an overly strict standard of qualification would make it difficult and in some instances virtually impossible to secure a qualified expert witness. (11 Cal.3d at pp. 644-646, fn. omitted.) The court concluded the determinative issue in each case must be whether the witness has sufficient skill or experience in the field so that his testimony would be likely to assist the jury in the search for the truth, and no hard and fast rule can be laid down which would be applicable in every circumstance. (11 Cal.3d at p. 645.) Where a witness has disclosed sufficient knowledge, the question of the degree of knowledge goes more to the weight of the evidence than its admissibility. ( Chadock v. Cohn (1979) 96 Cal. App.3d 205, 209 [157 Cal. Rptr. 640].) (7c) Dr. Fox is a diplomate in surgery and neurosurgery, and it would be unreasonable to assume that he does not regularly read X-rays and radiologists' reports and is unfamiliar with the standard of care exercised by radiologists in reading X-rays and preparing reports. In considering the claim that Dr. Fox is not shown competent to testify to the standard of care exercised by the various other specialists, it must be remembered that his challenge is they failed to diagnose the broken neck. The fact that the patient exhibits symptomatology coming within a particular specialty does not mean that there is not disease or injury coming within another specialty. A specialist must be alert to such possibilities and the need to consult other specialists. The specialist treating respiratory problems, in other words, must be alert to the possibility that the respiratory problems are caused in whole or in part by spinal dislocations and be prepared to call in neurosurgeons when proper diagnostic procedures so require. Defendants argue that as a surgeon and neurosurgeon Dr. Fox has qualifications not possessed by the other specialists, that a higher standard of care would be applicable to a neurosurgeon than to doctors engaged in other specialties, and that his declaration as to the standard of care could be rejected on the basis that he is in a sense overqualified. However, a neurosurgeon is obviously aware not only of the practice of his speciality but also the symptomology which leads other specialists to treat patients coming within his speciality and to refer patients to neurosurgeons. (17) Defendants rely on authorities that hold that the qualification of an expert is ordinarily a matter addressed to the sound discretion of the court and its ruling will not be disturbed unless a clear abuse is shown. ( Chadock v. Cohn, supra, 96 Cal. App.3d 205, 208.) However, the court will be deemed to have abused its discretion if the witness has disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury. ( Brown v. Colm, supra, 11 Cal.3d 639, 647.) (7d) As a diplomate of surgery and neurosurgery, Dr. Fox is qualified to testify as to the standard of care in reading X-rays, in submitting X-ray reports, and in diagnosing, and the court abused its discretion in concluding that there was no proper foundation. (18) Defendants also urge that because Dr. Fox was not listed by plaintiffs as one of their experts for trial, he could not be called as a witness at trial (Code Civ. Proc., § 2037 et seq.) and that because the purpose of a summary judgment motion is to determine whether there are any triable issues of fact, the court in ruling on the summary judgment motions was required to disregard Dr. Fox' declaration. At the argument on the summary judgment motions, plaintiffs asserted that they had recently obtained the services of Dr. Fox. [9] Code of Civil Procedure section 2037.6 provides that the court upon such terms as may be just may permit a party to call an expert witness not included in the list of expert witnesses so long as the court finds that the party made a good faith attempt to list expert witnesses, that the party has given notice to the opposing party in accordance with section 2037.4, and that as of the date of the exchange of lists the party would not in the exercise of reasonable diligence have determined to call such witness. [10] Because the trial court might choose to grant relief, the court ruling on the motions for summary judgment could not assume that it would not. For the foregoing reasons, we conclude that the court could not properly reject Dr. Fox' declaration on the grounds it stated. This does not mean that the summary judgment motions must be denied as to all defendants. Because the judge rejected Dr. Fox' declaration for all purposes, he had no occasion to reach the further issue that the declaration was sufficient to give rise to issues of fact as to some defendants but not others. Although Dr. Fox states generally that the physicians should have been alerted to the fracture on the basis of certain X-rays and the patient's complaints and symptoms, it is apparent that many of the defendants were not involved in the reading of the X-rays reflecting the fracture, and the declaration does not specify the particular complaints or symptoms or indicate when they occurred. The statements that the doctors generally should have been alerted to the fracture are obviously conclusionary and do not furnish a basis for denial of the summary judgment motions made by individual doctors. Upon remand, the judge should consider as to each defendant whether there is a factual basis for liability shown by Dr. Fox' declaration or any additional declaration that may be filed.