Opinion ID: 901718
Heading Depth: 1
Heading Rank: 6

Heading: Admissibility of the Stipulation to Cross-Examine Dr. Schwartz

Text: [¶ 26.] The trial court allowed Dr. Schwartz to testify as a fact witness without inquiry into the Stipulation and his licensure probation on the condition that Dr. Schwartz refrain from offering any opinion as to the applicable standard of care. Mousseau avers that notwithstanding this demarcation between fact and expert testimony, Dr. Schwartz effectively appeared as an expert witness by virtue of the highly technical nature of his testimony about how he arrived at his diagnosis of Mousseau's condition and his recommendations to her, as well as the manner in which he described the procedures he performed on her. Simply stated she asserts that, in the eyes of the jury, Dr. Schwartz was providing technical, expert testimony, regardless of whether he specifically stated any opinions regarding the standard of care. See Block, 126 N.W.2d at 812 (holding that [l]aymen cannot be expected to possess the technical knowledge and experience required to intelligently second guess a physician on diagnostic procedures and the conclusions to be drawn therefrom; this is especially true in a case such as this where the [ ] nervous system [ ] of the human body [is] involved) (emphasis added). Mousseau, therefore, argues that Dr. Schwartz should have been available for cross-examination about the Stipulation and the nature of his conditional licensure that was in effect at the time of trial, as it went to his knowledge, skill, learning, and training in the field of neurosurgery and thus the credibility of his testimony. See State v. Litschewski, 1999 SD 30, ¶¶ 22, 23, 590 N.W.2d 899, 903 (recognizing that where a witness makes an issue of his credibility by favorable direct testimony, he `opens the door' to impeachment evidence on cross-examination) (citations omitted). [¶ 27.] The excerpts of Dr. Schwartz's testimony are replete with explanations of his diagnostic findings prior to both the June 6 and November 1, 2001 surgeries and how they supported his conclusions about recommended courses of treatment for Mousseau's condition preceding the respective surgeries. [15] Dr. Schwartz offered testimony as to percentage rate for various types of complications that could potentially arise during or as a result of the procedures he proposed. He also testified to the practice that he and others would follow during the various stages of the procedure that he performed on Mousseau and what he would do if complications arose. Most significantly, however, when Dr. Schwartz testified in regard to the probability that vertebral instability might develop as a result of the June 6, 2001 surgery by stating that the chances of that happening are so low that there's really no indication to do a fusion up front, he directly contradicted the expert testimony of Dr. Teuber. One of the ways Dr. Teuber testified that Dr. Schwartz had failed to meet the applicable standard of care was that he should have recognized that the laminectomy performed at the L3-L4 vertebral segment actually weakened the spine in that location resulting in a clinically significant retrolisthesis, see supra n. 6, at that segment necessitating the fusion surgery at that segment performed on November 1, 2001. See supra ¶ 3. [¶ 28.] While in the view of the trial court, Dr. Schwartz's testimony constituted that of a percipient fact witness, conveying only his observations of his examinations of and surgeries performed on Mousseau and refraining from testifying to an applicable standard of care, it is apparent that his testimony amounted to an expert medical opinion offered by a witness with highly specialized knowledge in a field beyond the scope of a layman's independent comprehension. See State v. Fool Bull, 2008 SD 11, ¶ 29, 745 N.W.2d 380, 389 (concluding that an emergency room physician called by the State as a percipient observer in regard to her examination of a rape victim offered testimony that amounted to expert opinion); see also Orth v. Stoebner & Permann Const., Inc., 2006 SD 99, ¶ 44, 724 N.W.2d 586, 596 (reiterating in a case where we found that a physician stated with a satisfactory degree of medical probability that a work-related injury and degenerative condition respectively accounted for fifty percent each for the plaintiff's condition that [t]here are no `magic words' needed to express an expert's degree of medical certainty, and the test is only whether the expert's words demonstrate that he or she was expressing an expert medical opinion) (quoting Stormo v. Strong, 469 N.W.2d 816, 824 (S.D. 1991)); Ward v. Epting, 290 S.C. 547, 351 S.E.2d 867, 872 (1986) (holding that the defendant physician, who took the witness stand as a mere party and not an expert, did effectively offer expert testimony based in part on the fact that she testified to routine surgical and recovery room procedures in addition to her own actions and to a reasonable degree of medical certainty as to how the subject event in the case at bar occurred). [¶ 29.] Moreover, while Dr. Schwartz did not expressly offer testimony as to his opinion on the applicable standard of care, we conclude that he in effect did so. From Dr. Schwartz's testimony as to the practice that he and others would follow during the various stages of the procedures that he performed on Mousseau, we can infer that he was testifying to an applicable standard of care. To conclude otherwise would be to surmise that Dr. Schwartz disavows the application of a standard of care or at best is ambivalent about such a standard. See McCurdy v. Hatfield, 30 Cal.2d 492, 183 P.2d 269, 271 (1947) (holding that while the defendant physician did not expressly testify to an applicable standard of care, his testimony did amount to what constituted proper practice, and thus, could reasonably be inferred to constitute testimony as to a standard of care ordinarily applied by physicians under like circumstances); Huffman v. Lindquist (Huffman I), 213 P.2d 106, 110 (Cal.App.,1950), vacated on other grounds by Huffman v. Lindquist (Huffman II), 37 Cal.2d 465, 234 P.2d 34 (1951); Dickow v. Cookinham, 123 Cal.App.2d 81, 266 P.2d 63, 65-66 (Cal.App., 1954); see also Huffman II, 234 P.2d at 41 (reasoning that where a defendant physician, who does not expressly testify to an applicable standard of care, but does in effect testify to a proper practice, it is presumed that the practice is based on the applicable standard of care and if the defendant physician does not therewith conform, a prima facie case of negligence is therein established). [¶ 30.] Still, Dr. Schwartz argues that, in any case, the trial court properly excluded the Stipulation evincing his licensure probation and the conditions thereon. He cites Boomsma v. Dakota, Minnesota & Eastern R.R. Corp., 2002 SD 106, 651 N.W.2d 238, overruled on other grounds by State v. Martin, 2004 SD 82, 683 N.W.2d 399; Sommers v. Friedman, 172 Wis.2d 459, 493 N.W.2d 393 (Ct.App. 1992); Soto v. Lapeer County, 169 Mich. App. 518, 426 N.W.2d 409 (Ct.App., 1988); and King v. Ahrens, 16 F.3d 265 (8th Cir.1994) for the proposition that under the circumstances of the instant case, evidence pertaining to the status of professional licensure is not a proper subject of cross-examination. However, these cases are distinguishable from the case on appeal. [¶ 31.] In Boomsma, the trial court refused to admit evidence that plaintiff's expert had voluntarily relinquished his optometry license and defendant appealed. 2002 SD 106, ¶ 48, 651 N.W.2d at 248. Unlike the instant case where Dr. Schwartz acknowledged by way of the Stipulation that his licensure probation was attributable to malpractice, in Boomsma, the plaintiff's expert was merely the subject of allegations of misconduct. This case lends no support to Dr. Schwartz's position. Our affirmance of the trial court in Boomsma was based on the court's reasoning that in lieu of any evidence of misconduct, allowing testimony which amounted to no more than mere allegations of misconduct would be more prejudicial than probative. Id. ¶ 51 [¶ 32.] In Sommers, the plaintiff sought to cross-examine the defendant physician about the fact that she had failed two voluntary internal medicine specialty board certification exams three years and four years respectively prior to examining the decedent. 493 N.W.2d at 397. The plaintiff asserted that the exam failures were relevant to the defendant's overall competency and that they were the proper subject of impeachment because she alleged the defendant offered expert opinions on the subject matter underlying the exams. In refusing the plaintiff's request, the trial court reasoned that the defendant offered only very limited opinion testimony and that the exam failures were of limited relevance to the manner in which she examined the decedent. Id. at 397-98. Contrasted with Sommers, in the instant case, Dr. Schwartz offered a voluminous amount of medical opinion testimony in regard to the diagnosis and treatment of Mousseau. And, the licensure probation and conditions set out in the Stipulation were relevant to the level of credibility that the jury might assign to Dr. Schwartz's seemingly competent testimony. [¶ 33.] In Soto, the trial court ruled that the plaintiff could not question the defendant physician about a consent order whereby he agreed to a probationary period during which his license was restricted. 426 N.W.2d at 411-12. In affirming the trial court, the appellate court noted that the consent order arose out of an administrative complaint filed against the defendant concerning a specific procedure performed on a particular patient, that it did not arise out of the case at bar, and that it did not involve any procedure performed by the defendant in the case at bar. Id. at 412. The nature of the Stipulation in the instant case is dissimilar in that although it may have arisen out of Dr. Schwartz's malpractice in regard to other patients, the procedures giving rise to his stipulated conditional licensure were neurosurgical spine procedures. [¶ 34.] Finally in King, that trial court refused to allow evidence that the defendant physician's medical license had been suspended for thirty days some eight years prior to trial. 16 F.3d at 268. King is inapposite to Dr. Schwartz's five-year conditional licensure probation that began twenty-six months prior to trial. With reference to the balancing test applied under Rule 403, [16] the Eighth Circuit Court of Appeals stated: The danger of unfair prejudice is substantial and immediately apparent in this case for several reasons. The license suspension by its very nature reflects badly on [the defendant's] professional conduct, although this alone does not amount to unfair prejudice. Additional factors to weigh include the remoteness of the license suspension to the incident at issue, the suspension having occurred approximately eight years before [the defendant's] examination of Mr. King. The license suspension did not arise out of the same or similar circumstances as the incident at issue. Further, the veracity of [the defendant] and his medical chart were subject to thorough impeachment at trial by inconsistencies readily apparent in his testimony, the medical chart, and his deposition, and the past license suspension would have shed little new light on [the defendant's] character for truthfulness. Thus, in spite of the peripheral relevance of the suspension, there was great danger that the jury might improperly infer from the fact of a distant and unrelated past license suspension that [the defendant's] professional judgment and conduct in the instant case must have been substandard solely because his license had been suspended on a prior occasion. Given the danger that this evidence might influence a jury to decide the case on an improper basis and the great deference with which we review this evidentiary ruling, we cannot say that the district court abused its discretion in determining that the danger of prejudice outweighed the probative value of the license suspension. Id. at 269-70 (emphasis in original). [¶ 35.] In the instant case, both Dr. Schwartz and Mousseau thoroughly briefed the issue of whether to allow reference to the Stipulation, and fully argued factors for and against admission during a pretrial motions hearing. The trial court appears to have ruled in favor of exclusion without balancing the probative value against the danger of unfair prejudice or providing any justification on the record. [¶ 36.] Our review of the record reveals no basis similar to that cited by the court in King, 16 F.3d at 269-70, as to why the Stipulation should not be admitted into evidence or available for Mousseau to use during cross-examination of Dr. Schwartz. The Stipulation was relevant to the degree of knowledge and skill in the field of neurosurgery possessed by Dr. Schwartz during the time proximate with the procedures he performed on Mousseau. Accordingly, it was relevant to his credibility as a witness who effectively gave expert testimony in the field of neurosurgery. While evidence of, or inquiry into, Dr. Schwartz's licensure probation and conditions thereon would no doubt have been prejudicial to him, the probative value of that evidence outweighs the prejudicial effect upon Dr. Schwartz in the context of his having had the chance to offer highly technical, effectively expert testimony to the jury without any challenge to the credibility of his supposedly competent testimony. [¶ 37.] Alternatively, Dr. Schwartz argues that to admit the Stipulation would violate SDCL 19-14-10 (Rule 608(b)), because he argues the probationary status of his license is not probative of his reputation for truthfulness. Rule 608(b), codified under SDCL 19-14-10 provides: Specific instances of the conduct of a witness, for the purpose of attacking or supporting his credibility, other than conviction of crime as provided in §§ 19-14-12 to 19-14-16, inclusive, may not be proved by extrinsic evidence. They may, however, in the discretion of the court, if probative of truthfulness or untruthfulness, be inquired into on cross-examination of the witness: (1) Concerning his character for truthfulness or untruthfulness; or (2) Concerning the character for truthfulness or untruthfulness of another witness as to which character the witness being cross-examined has testified. [¶ 38.] We addressed this precise issue when presented to the Court for review by Dr. Schwartz in Kostel, 2008 SD 85, ¶ 13, 756 N.W.2d 363, 370. Thus we need not revisit our analysis of the proper scope of application for Rule 608(b), other than to reiterate our holding: [W]hile inquiry into an expert's alleged mistakes or connection to unrelated adverse claims do not impact on his credibility or character for truthfulness, evidence contrary to the representation of the witness's expertise in the field for which he offers his opinion at bar is relevant to his competency, does impact credibility and therefore is appropriate inquiry. Id. ¶ 14 (emphasis original) (citations omitted). [17] Furthermore, in Kostel, we restated our prior recognition that when a witness places his credibility at issue through favorable direct testimony, he `opens the door' to impeachment on cross-examination pursuant to SDCL 19-14-8 (Rule 607), [18] even in instances when evidence is not otherwise admissible under Rule 608(b). Id. ¶ 20 (citing Litschewski, 1999 SD 30, ¶¶ 22, 23, 590 N.W.2d at 903) (quoting State v. Byrum, 399 N.W.2d 334, 337-38 (S.D.1987)) (citations omitted). [¶ 39.] Finally, Dr. Schwartz argues that inclusion of the Stipulation would violate the provisions of SDCL 36-4-31.5, [19] which establishes as confidential, witness testimony and documentary evidence in license cancellation, revocation, suspension, or limitation proceedings conducted by the Board. However, our review of the Stipulation reveals that it does not include any information from the Board proceeding itself, which is the focus of the confidentiality statute. Therefore, the provisions of SDCL 36-4-31.5 are not invoked by inclusion of the terms and conditions of Dr. Schwartz's probation as provided in the Stipulation. Moreover, since Dr. Schwartz consented that the terms of the Stipulation constituted a public record, see supra ¶ 7, his claim that SDCL 36-4-31.5 precludes admission of the Stipulation is without merit. [¶ 40.] Dr. Schwartz established his neurosurgery practice in June 2000, immediately after completing his residency. One year later, he performed the first of two procedures on Mousseau. Mousseau alleges that during the first procedure on June 6, 2001, Dr. Schwartz failed to meet the applicable standard of care by leaving untreated, areas of her spine that needed treatment, while at the same time weakening others, thereby necessitating spinal fusion surgery on November 1, 2001. She further alleges that the accumulation of scar tissue following the first surgery led to Dr. Schwartz again failing to meet the applicable standard of care by damaging nerve roots while conducting the second surgery, resulting in permanent back pain and leg weakness. During the time proximate with Mousseau's surgery, Dr. Schwartz conducted procedures on other patients from which claims of malpractice were raised. Ultimately, Dr. Schwartz entered into the Stipulation with the Board whereby his license was placed on probationary status with numerous conditions precedent to his full reinstatement, including retraining in his chosen field and group practice for five years thereafter. The reason given by the Board for the sanctions was Malpractice. [¶ 41.] The Stipulation was evidence of a deficiency in Dr. Schwartz's knowledge and skill in the field of neurosurgery that related directly to his ability to meet the applicable standard of care by possessing and using the skill and care ordinarily possessed and used by neurosurgeons under like circumstances. In addition, the Stipulation was relevant to challenge the credibility of Dr. Schwartz's highly technical, effectively expert testimony regarding his diagnostic findings and conclusions and the manner in which he conducted the surgery on Mousseau. Finally, as a public record, there was no basis in this case for the exclusion of the Stipulation. Accordingly, we conclude that the trial court abused its discretion by excluding the Stipulation. Because the terms and conditions therein went to vital matters in the case  the level of knowledge and skill possessed by Dr. Schwartz and the credibility of his testimony  exclusion of the Stipulation in all probability affected the outcome of the jury's verdict and thereby constitutes prejudicial error. See Carpenter v. City of Belle Fourche, 2000 SD 55, ¶ 23, 609 N.W.2d 751, 761; Kjerstad, 517 N.W.2d at 427. [¶ 42.] Reverse and remand for further proceedings consistent with the foregoing opinion. [¶ 43.] ZINTER and MEIERHENRY, Justices, and WILBUR and HOFFMAN, Circuit Judges, concur. [¶ 44.] WILBUR, Circuit Judge, sitting for SABERS, Justice, disqualified. [¶ 45.] HOFFMAN, Circuit Judge, sitting for KONENKAMP, Justice, disqualified.