Opinion ID: 2194643
Heading Depth: 3
Heading Rank: 1

Heading: Appellants' expert failed to establish the basis for his national standard of care testimony.

Text: Dr. Bloss failed to establish a basis for his knowledge of the national standard of care for the treatment of osteomyelitis. We do not agree, as appellants' contend, that Dr. Bloss's general knowledge in the field of orthopedic surgery, which was sufficient for him to satisfy the first threshold requirement for qualifying as an expert, was sufficient to satisfy the second threshold requirement of demonstrating that his opinion testimony was grounded in and based on a national standard of care. Standing alone, Dr. Bloss' testimony regarding his educational and professional background, was insufficient to establish a basis for his knowledge of a national standard of care, and merely amounts to the expert's personal opinion. See Strickland, supra, 899 A.2d at 774. Appellants' counsel attempted to elicit testimony from Dr. Bloss that to treat Mr. Hill's infection, all of the hardware should have been removed during the second operation with Dr. Levitt. Further, counsel attempted to elicit testimony establishing that when Dr. Levitt left two screws in Mr. Hill's leg, his conduct did not comport with the national standard of care. However, appellee's counsel objected, based on lack of foundation, and the objections were sustained by the trial court. Ms. Holt (appellants' counsel): Do you have experience in osteomyelitis? You have already told us you do, is that accurate? Dr. Bloss: Yes. Q. . . . you also have experience in the treatment of osteomyelitis, you told us, right? A. Yes. Q. And as a result of your experience in the treatment of osteomyelitis, is there a reason why you as an orthopedic surgeon would want to remove the hardware of a person who has developed osteomyelitis? Mr. Montedonico (trial counsel for Dr. Levitt) Objection; foundation. The court: Sustained. Ms. Holt: Court's indulgence for a moment. Q. Have you had experience-have you had experience in removing the hardware after a person develops osteomyelitis? A. Yes, many times. Q. Could you give an estimate? A. Hundreds. . . . . Q. And were these people who had open reduction and internal fixation A. Some of them. Q. In your experience, did you have a reason for removing the hardware after they developed? Mr. Montedonico Objection again to the foundation, what he does. . . . The court: I will sustain as to the form. Ms. Holt: Are you aware of practices of other physicians with respect to removal of the hardware after a person has osteomyelitis and he has had open reduction and internal fixation? Mr. Montedoncio: Objection; lack of foundation. The court: Sustained. Ms. Holt: During your training doctor, did you study the subject of open reduction and internal fixation? A. Yes. Q. Did you study the risk involved in open reduction and internal fixation? A. Yes. Q. And, you had an opportunity-let me go in particular to where you were interning with Dr. Seligson, during that period of time did you work with people who had osteomyelitis? A. Yes. Q. And were those people who had osteomyelitis following trauma, and surgical repair? A. Yes, most of them. Q. Any, in any of those cases did you make recommendation for removal of the hardware? A. Yes. Mr. Montedonico: Objection The court: Basis. Mr. Montedonico: What he did with some unknown patient is not relevant to this case. The court: Sustained. . . . Q. Let me ask it this way. Is it standard practice in the field of orthopedic surgery to remove hardware after a person has had open reduction and internal fixation and there appears to be an infection? A. Yes. Mr. Montedonico: Objection The court: Basis. Mr. Montedonico: Lack of foundation. . . . Ms. Holt: Can you tell us some name of some treatises that deal with the subject? . . . Mr. Montedonico: Objection. This is not permissible under direct examination. [10] . . . Ms. Holt: I should not just ask you familiar standards. Is it necessary for you as an orthopedic surgeon operating on people who have osteomyelitis to know the standards for determining why hardware should be removed? A. Yes. Q. Okay. And what is the reason why an orthopedic surgeon would remove hardware after a person has had open reduction and internal fixation, followed by osteomyelitis. Mr. Montedonico: Objection. Bench Conference: . . . Ms. Holt: No, I'm not [understanding the objections]. I know that there was an objection to his qualification, but he was qualified as an orthopedic surgeon. He is now testifying to what orthopedic surgeons do. The court: He can't just sort of give these generalities about what they do. We are talking about this case, his opinions in this case and what he reviewed, and what he looked at in this case and so on and so forth. Or he can say that he is familiar with the procedures. He has said that. Now you are just talking about what people do in the world, people remove screws, people remove hardware. . . . He is saying in a hundred cases some place somebody might remove some hardware where a person has osteomyelitis and reduction in internal fixation . . . we need to talk about this case and his opinions in this case, his review of this case, and why he has reached certain opinions. Ms. Holt: When I get to assess more foundation to lay before him to show that he has a factual basis for giving an opinion in this case. [sic] That is all I am trying to show that he has a factual basis for it. The court: When you get there, you will get to where you need to be. The trial court correctly concluded that the appellant never got there and never established the basis for Dr. Bloss' knowledge of a national standard of care, what the national standard of care was, or the basis for his opinion that Mr. Hill's doctors deviated from the national standard. Instead, Dr. Bloss repeatedly stated his personal views and his practices and procedures. He failed to link his views to a national standard of care. The trial court concluded: The motion is granted for the following reasons. Ms. Holt may recall that after sustaining several objections by the defense to certain testimony being offered by Dr. Bloss, the parties came to the bench. And Ms. Holt inquired of the Court words to the effect of, well, I don't know what I'm doing along here. I may not be putting it exactly right. And I said, well, Ms. Holt, well, I will tell you, I would be telling you what to do, which I don't think the defense wants me to do. And I said that because I knew that if I said much more and I forced Mr. Montedonico [Dr. Levitt's counsel] to probably go a little bit further in stating the grounds of his objection, tha[n] he wanted to as well as Mr. Costello [Dr. DiPasquale and WHC's counsel]. Because if I said it, I would tell you what was missing. At least I felt that way. Maybe I was wrong. But [I] felt that danger. The reason the objections were being sustained as to lack of foundation, in my view, was because there had been no testimony as to the national standard of care. And the questions were being phrased, Dr. Bloss, is it your opinion within a reasonable degree of medical certainty and the national standard of care, that W, X, Y and Z and there had been no testimony as to the national standard of care. I have reviewed my notes and while there was testimony by Dr. Bloss concerning a number of things, he began by explaining cortex tibia, distal, close fracture, open fracture, commuted fracture, crush injury. He talked about his familiarity with the procedures of open reduction and external fixation. He talked about the use of anesthesia, local or general in those circumstances. He talks abouthe talked about healing in that regards. He talked about external fixation. He talked about his dealing with the fractures of the tibia and fibula, and about the factors to use an external fixation. But he never talked about a national standard of care in that regard, either his familiarity with it nor what it is. Dr. Bloss's testimony was fatally flawed in two respects: first, Dr. Bloss appeared to be giving his personal opinion based on his experience; and second, Dr. Bloss never referenced the basis for knowledge of a national standard of care, what the national standard was, or the basis of his opinion that Dr. Levitt's conduct fell below the standard of care. As we have previously held, an expert in a medical malpractice case must establish the basis for his knowledge of the applicable national standard of care and link his opinion testimony to the applicable national standard. In a medical malpractice case, the plaintiff must establish the applicable standard of care, a deviation from that standard and a causal relationship between the deviation and the injury. See, e.g., Travers v. District of Columbia, 672 A.2d 566, 568 (D.C.1996). Through expert testimony regarding the applicable national standard of care, the plaintiff must establish, the course of action that a reasonably prudent doctor with the defendant's specialty would have taken under the same or similar circumstances. Strickland, supra, 899 A.2d at 773 (quoting Meek v. Shepard, 484 A.2d 579, 581 (D.C. 1984)). The personal opinion of the expert is insufficient, the expert must establish that a particular course of treatment is followed nationally either through reference to a published standard, discussion of the described course of treatment with practitioners outside the District at seminars or conventions, or through presentation of relevant data. Strickland, supra, 899 A.2d at 773-74 (internal quotations and citations omitted) (emphasis added); see also Snyder, supra, 890 A.2d at 241 n. 3; Hawes v. Chua, 769 A.2d 797, 806 (D.C. 2001); Travers, supra, 672 A.2d at 568-69. In Snyder, this court reversed a trial court's grant of a directed verdict holding that the physician's expert testimony was sufficient to establish a national standard of care and deviation from that standard. Snyder, supra, 890 A.2d at 239. In Snyder, the expert did not use the exact term `national standard of care' but testified that his knowledge of the standard of care was based upon attendance at national meetings and keeping up to date with literature with regard to the national standard. Id. at 245-46. Likewise, in Hawes, we concluded that the expert's testimony was minimally sufficient for admission into evidence. Hawes, supra, 769 A.2d at 808. In Hawes, the court laid out seven principles that are important in assessing the sufficiency of national standard of care testimony, when an expert has already been qualified to give an expert opinion: First, the standard of care focuses on the course of action that a reasonably prudent doctor with the defendant's specialty would have taken under the same or similar circumstances. Second, the course of action or treatment must be followed nationally. Third, the fact that District physicians follow a national standard of care is insufficient in and of itself to establish a national standard of care. Fourth, in demonstrating that a particular course of action or treatment is followed nationally, reference to a published standard is not required, but can be important. Fifth, discussion of the course of action or treatment with doctors outside this jurisdiction, at seminars or conventions, who agree with it; or reference to specific medical literature, may be sufficient. Sixth, an expert's personal opinion does not constitute a statement of the national standard of care; thus a statement only of what an expert would do under similar circumstances is inadequate. Seventh, national standard of care testimony may not be based upon mere speculation or conjecture. Hawes, supra, 769 A.2d at 806 (internal citations and quotations omitted). When the expert in Hawes was asked the basis for his opinion with respect to the national standard of care, he testified that his testimony was based on reading literature in his specialty, attendance at national meetings and the standard of the American College of Obstetrics and Gynecology, which provided an accepted national standard of care to physicians in his field. Hawes, supra, 769 A.2d at 807. Similarly, in Washington v. Washington Hosp. Ctr., 579 A.2d 177, 182 (D.C.1990), we concluded that there was sufficient evidence to establish a national standard of care. The expert in Washington did state his personal opinion, but also testified that the basis of his conclusion, that carbon dioxide monitors were required in operating rooms, was founded on several national publications. Id. This case is distinguishable from Washington, where we concluded that there was other evidence in the record, which in combination with the expert's testimony, established a standard of care. Washington, supra, 579 A.2d at 183. For instance, there was evidence that other teaching hospitals in the United States used the carbon dioxide monitors at issue; WHC's expert testified that the hospital he practiced at had the carbon dioxide monitor's and that many hospitals were converting to using carbon dioxide monitors. Id. Additionally, WHC's Chairman of Anesthesiology testified that the monitors were necessary to comport with the national standard of care. Washington, supra, 579 A.2d at 183. The record in this case lacks similar evidentiary support. In contrast to Washington and Hawes, Dr. Bloss was never asked by counsel what was the basis of his knowledge of the national standard of care and what was the basis of his opinion that appellant's doctors deviated from the national standard. Nor did Dr. Bloss provide an independent basis that his opinion, regarding the removal of the hardware, was based upon literature, speaking with other doctors around the country, attending medical conferences, or reviewing published national standards. Additionally, in contrast to Washington, there was no evidence admitted from which the national standard could have been inferred, although appellant's counsel did pose several questions to Dr. Bloss with respect to the national standard of care. For instance, here, appellants' counsel asked when you testify here today are you here to testify to local standards or to national standards, and are you aware of practices of other physicians with respect to removal of the hardware after a person has osteomyelitis and he has had open reduction and internal fixation. However, the objections to these questions were appropriately sustained because no proper foundation was established to demonstrate the basis of Dr. Bloss' knowledge of the national standard of care. To the contrary, this case is more like our cases where we have concluded that the expert's testimony failed to establish the national standard of care. See, e.g., Strickland, supra, 899 A.2d at 770. In Strickland, we concluded that the expert's testimony had failed to establish a national standard of care and, we affirmed the trial court's grant of a Motion for Judgment. Id. In that case, appellant's expert was offered to establish that the appellees breached the national standard of care by failing to perform additional tests when the decedent initially reported to the emergency room complaining of chest pains. Id. We reasoned that mere reference to an expert's educational and professional background was insufficient to establish a national standard of care. Id. at 774. We, therefore, held that the expert's testimony amounted to nothing more than that expert's personal opinion. Like the expert in Strickland, Dr. Bloss failed to establish the basis for his testimony and opinion regarding the national standard of care for the treatment of osteomyelitis. Although counsel for appellant asked when you testify here today are you here to testify to local standards or to national standards, [11] even if Dr. Bloss had responded in the affirmative, merely noting that the testimony was based upon a national standard was insufficient, unless he had first established the basis for his knowledge of the national standard. Further, Dr. Bloss was asked, are you aware of practices of other physicians with respect to removal of the hardware. This question lacked a proper foundation because a basis was never established for his knowledge of the practices of other physicians on the removal of hardware. Mr. Hill's counsel also asked Dr. Bloss is it standard practice in the field of orthopedic surgery to remove hardware after a person has had open reduction and internal fixation. The objection to this question was properly sustained because Dr. Bloss could not testify as to what the national standard was without the adequate foundation establishing the basis for his knowledge of a national standard. See Strickland, supra, 899 A.2d at 774 (Dr. Stark made repeated references to a standard and claimed that it was applicable in this case . . . [w]ithout any supplemental support, however, this testimony amounted to nothing more than the expert's opinion.). Dr. Bloss's testimony is like the testimony in Strickland, where we stated, The only attempt that the expert made to reference a national standard was by stating in rather general terms that his opinion was [w]hat other similarly trained doctors would have done under similar circumstances, or that it was the standard of care what doctors do in hospitals around the country. Even after explicit direction from the trial judge, Dr. Stark made no attempt to link his testimony to any certification process, current literature, conference or discussion with other knowledgeable professionals, any of which would have established a basis for his discussion of the national standard of care. Strickland, supra, 899 A.2d at 774. It is counsel's duty to lay the necessary foundation to establish the national standard of care. It is not sufficient to rely on an expert's background or professional experience, nor is a simple statement that something does or does not comport with the national standard of care sufficient. The expert must explicitly indicate the basis for his or her knowledge of the national standard of care, state what the national standard of care is, and provide a basis for his or her opinion testimony that another doctor has deviated from that standard. That was not done here. As such, the trial court did not err in granting judgment to appellees on this issue.