Opinion ID: 1936466
Heading Depth: 1
Heading Rank: 9

Heading: Einspahr's Opinion on Causation

Text: To prove the causal connection between his bladder condition and the collision, Dean relied on the testimony of Einspahr. As noted, Einspahr is not a urologist. Rather, he is a specialist in internal medicine. He has no training in urology other than what was required while he was in medical school. Einspahr, however, testified that Dean's urological symptoms include the types of symptoms he would evaluate during the ordinary course of his practice as an internist. As discussed earlier, Einspahr originally expressed no opinion as to the cause of Dean's bladder condition; he only ruled out the possibility that infection was the cause. But in the summer of 2000, Einspahr, at the request of Dean and his counsel, reevaluated Dean. After this reevaluation, Einspahr came to the conclusion that the collision had caused Dean to develop the neurogenic bladder condition. At trial, he testified to this to a reasonable degree of medical certainty. Einspahr based his conclusion that the collision had caused Dean to develop neurogenic bladder on the results of a differential diagnosis. Within the medical community, differential diagnosis appears to be a generic term, which is used to refer to a variety of diagnostic techniques. See, generally, Jerome P. Kassirer & Richard I. Kopelman, Learning Clinical Reasoning 112-14 (Williams & Wilkins 1991) (commenting on fuzzy and incomplete concept and outlining five forms of differential diagnosis). But within the legal world, an entire subset of case law evaluating the reliability of the differential diagnosis technique has developed. Generally, these courts explain that [i]n performing a differential diagnosis, a physician begins by `ruling in' all scientifically plausible causes of the [patient's] injury. The physician then `rules out' the least plausible causes of injury until the most likely cause remains. Glastetter v. Novartis Pharmaceuticals Corp., 252 F.3d 986, 989 (8th Cir.2001). See, also, Schafersman v. Agland Coop, 262 Neb. 215, 631 N.W.2d 862 (2001). This is consistent with the technique that Einspahr employed, and it is the meaning of differential diagnosis that we will use in the remainder of our discussion. As noted earlier, there are several potential causes for bladder retention. These include obstruction in the urinary tract, enlarged prostate, and infection. In addition, bladder retention can be caused by those conditions that fall under the general rubric of neurogenic bladder: (1) injury to the individual nerve fibers that serve the bladder, (2) injury to the nerve that those nerve fibers run in, (3) injury to or disease of the spinal cord, (4) injury to or disease of the brain, and (5) idiopathic neurogenic bladder. In conducting his differential diagnosis, Einspahr considered each of these possibilities. Einspahr then considered the ruling out portion of his analysis. Based on the reports of Henslee and Pattee, Einspahr was able to rule out obstructions to the urinary tract, multiple sclerosis, injury to the spinal cord, and tumors in the spinal cord as possible causes for Dean's condition. In addition, his own examination of Dean had ruled out infection as the cause of Dean's bladder retention. After Dean saw McAninch, Einspahr reexamined Dean and found, as McAninch had, that Dean's prostate was now enlarged enough to cause bladder retention. But Einspahr did not believe that this fully explained Dean's condition. He noted that a prostate examination done by him in 2000 as well as Henslee's initial examination and the examination done at the Mayo Clinic had shown that Dean did not have an enlarged prostate. From this, he concluded that Dean had not developed an enlarged prostate until 4 years after his bladder retention problems had begun. Thus, it was Einspahr's opinion that two independent conditions were causing Dean's bladder retention: prostatic enlargement and neurogenic bladder. According to Einspahr, even if the enlarged prostate were operated on, Dean's bladder would still not function properly because of the neurogenic bladder condition. At this point in his analysis, Einspahr was left with two possible explanations for what had caused Dean to develop neurogenic bladder: (1) the collision caused trauma that injured the nervous system serving Dean's bladder or (2) he had idiopathic neurogenic bladder. Relying on the fact that Dean developed the bladder condition within weeks of the collision, Einspahr concluded that the collision was the more likely explanation for Dean's neurogenic bladder.