Opinion ID: 2135631
Heading Depth: 1
Heading Rank: 4

Heading: Dr. Kroeger's Deposition

Text: Kunnanzes argue that the trial court erred in not admitting significant portions of medical opinions from an audio-visual deposition of their expert, Dr. Robert Kroeger, because he was not asked whether those particular opinions were held to a reasonable degree of medical certainty. To support a finding of medical negligence, we have required expert medical opinions to be expressed in terms of reasonable medical certainty or probability, not mere possibility. Smith v. American Family Mutual Ins. Co., 294 N.W.2d 751 (N.D.1980); VanVleet v. Pfeifle, 289 N.W.2d 781 (N.D.1980); Vaux v. Hamilton, 103 N.W.2d 291 (N.D.1960). See also Syverson v. North Dakota Workmen's Comp. Bureau, 406 N.W.2d 688, 691 (N.D. 1987) (in order to justify workers compensation award, medical evidence need not hundred percent affirm a causal relationship between arthritic condition and employment). Our decisions have employed the magic words of reasonable medical certainty, but have also recognized that a medical opinion expressed in terms of reasonable probability suffices. Other courts have held that the evidentiary standard for admission of an expert medical opinion does not require the mechanical recitation of reasonable medical certainty and is satisfied if the expert expresses a medical opinion that is more probable, or more likely than not. Schulz v. Celotex Corp., 942 F.2d 204, 208 (3rd Cir.1991) (Care must be taken ... to see that the incantation does not become a semantic trap and the failure to voice it is not used as a basis for exclusion without analysis of the testimony itself.); Dallas v. Burlington Northern, 212 Mont. 514, 689 P.2d 273, 277 (1984) (Our evidentiary standards are satisfied if medical testimony is based upon an opinion that it is `more likely than not.'); Nunez v. Wilson, 211 Kan. 443, 507 P.2d 329, 332 (1973) ([E]vidence of probative value should not be excluded from the jury's consideration merely because a medical expert cannot state a fact with absolute certainty.); Shahan v. Hilker, 241 Neb. 482, 488 N.W.2d 577, 580 (1992) (A medical expert's testimony need not be couched in the magic words `reasonable degree of medical certainty or a reasonable probability.'); Stormo v. Strong, 469 N.W.2d 816, 824 (S.D.1991) ([T]he test is only whether the expert's words demonstrate that he or she was expressing an expert medical opinion.); Drexler v. All American Life & Cas. Co., 72 Wis.2d 420, 241 N.W.2d 401, 408 (1976) (No particular words of art are necessary....). See Hullverson, Reasonable Degree of Medical Certainty: A Tort Et A Travers, 31 St. Louis U.L.J. 577 (1987). Hypertechnical words are not necessary for the admission of an expert medical opinion; the test for admissibility is whether the expert's testimony demonstrates the expert is expressing a medical opinion that is more probable, or more likely than not. In this case, the trial court excluded the following deposition testimony of Dr. Kroeger: Q. [Sundling] What should Dr. Edge have done once the stone was pushed into the lower pole calyx? MR. PETERSON: I'm going to object as to foundation. A. In my opinion once you have determined that the stone is no longer in a position where you have a reasonable chance of getting it out with the ureteroscope, the prudent thing to do would be quit the ureteroscopy, and in this case probably just put up a stent and discuss options later on. Q. In response to the objection, is that what accepted standards required? A. In my opinion, yes.       Q. [Sundling] With the equipment that Dr. Edge was using could he have removed the stone from the lower pole calyx? MR. PETERSON: I'm going to object as that assumes facts not in evidence. We don't know what equipment you are referring to, Mr. Sundling. Secondly, it calls for speculation on the part of the doctor without further foundation. Q. (By Mr. Sundling) Let me see if I can fix the question. Doctor, using the equipment and particularly the ureteroscope that Dr. Edge was using at the time, was it technically possible to remove the stone from the lower pole calyx, and perhaps you can use a diagram? A. Right. MR. PETERSON: Before the doctor answers I also want to interpose the objection that there is no testimony that he was going to ever attempt to remove the stone from the lower calyx. That's assuming something not in evidence, as well. THE WITNESS: Okay. If the stone is in the lower calyx and we were working with the rigid ureteroscope, you can see that the scope goes up here, you have a chance of getting a stone out of the renal pelvis and into the upper pole. Because this particular scope cannot bend, your chances of actually going down and getting a stone in that lower calyx are virtually zero. Now, you know you could get lucky, you could irrigate and maybe the stone would float by you and you would be able to grab it. But it would not be a very high percentage proposition at all. Kunnanzes argue that the exclusion of this evidence prevented the jury from hearing that Dr. Edge violated accepted standards of care by continuing the ureteroscopy after the stone was pushed into the kidney. Dr. Kroeger's deposition testimony, as a whole, indicates he was expressing a medical opinion that was more probable, or more likely than not. Although the court excluded the above-quoted part of Dr. Kroeger's deposition testimony on a hypertechnical basis, the jury nevertheless heard the following testimony from Dr. Kroeger's deposition: Q. [Sundling] How long did he continue to try and remove the stone? A. I believe it was in the range of three and a half to four hours. Q. In your opinion was this below accepted standard of care to continue attempting to remove the stone once it had been pushed back into the lower pole calyx? A. Yes.       Q. [Cross-examination by Peterson] Now, do you have any criticism of Dr. Edge's use of thedilating the ureter as he is proceeding up with the scope? A. Yes, really, I think that is, in my experience that is seldom necessary. Now, certainly there may be, you know, one point in the ureter that you run into where you want to do that dilatation. But I think at that point what the reality of the situation is that you have got a ureter that you probably can't get your scope up and it's probably not prudent to proceed under those circumstances. And you always have the option of terminating the procedure, leaving up the stent, and coming back another day or considering an alternative form of treatment. Dr. Edge's expert witness, Dr. Irving Thorne, also testified on cross-examination: Q [Sundling] Now, Doctor, do you agree that if a kidney stone has been pushed back into the kidney to the point where it cannot be reached with a rigid ureteroscope, there is no reason to continue the ureteroscopy? A That's right. Q And as a matter of fact at that point it is below accepted standards of care to continue with the ureteroscopy? A If the stone was in an area where it could not be reached with the rigid ureteroscope? Q Yes. A That's right. Thus, the jury did hear expert testimony to support Kunnanzes' contention that Dr. Edge violated accepted standards of medical care by continuing the ureteroscopy after the kidney stone was pushed into Ernest's kidney. Since the excluded testimony was cumulative, the trial court's rigid ruling about reasonable medical certainty would not require a retrial. Kunnanzes assert that the trial court erred in excluding the following question on proximate cause during Dr. Kroeger's deposition testimony: Q. [Sundling] And, Doctor, did Dr. Edge's failure to follow accepted standards proximately cause the loss of Mr. Kunnanz' kidney? MR. PETERSON: I'm going to object as to that, that is a matter of factual question for the jury to determine and the issues of proximate causation are again matters of law and questions for the jury to decide in this case. This is not something that a medical physician is entitled to testify. Although the trial court excluded that question because there was no showing the witness knows what proximate means in a legal sense, rather than special sense, the court did not exclude Dr. Kroeger's answer immediately after that question: Q. (By Mr. Sundling) Doctor, do you have an opinion on that question? MR. PETERSON: Go ahead. A. Well, I certainly think that there was damage done to the ureter as a result of that procedure that set up a chain of events that led to the ultimate loss of the kidney, yes. N.D.R.Ev. 704 directs that opinion testimony is not objectionable because it embraces an ultimate issue to be decided by the trier of fact. See First Trust Co. of North Dakota v. Scheels Hardware, 429 N.W.2d 5 (N.D.1988). However, we do not believe Kunnanzes were prejudiced by the trial court's exclusion of one question about proximate cause, because immediately after that question, Dr. Kroeger answered in proximate cause language that the damage done to the ureter as a result of that procedure [by Dr. Edge] set up the chain of events that led to the ultimate loss of the kidney. [1] Kunnanzes assert that the trial court improperly excluded significant portions of Dr. Kroeger's opinion about the degree of care received by Ernest at the University of Minnesota Hospital, because their answers to interrogatories did not state that Dr. Kroeger would render an expert opinion on that issue. A trial court is vested with discretion to exclude expert testimony that is outside the scope of answers to interrogatories. Schwartz v. Ghaly, 318 N.W.2d 294 (N.D.1982). We review a trial court's ruling on that issue under an abuse-of-discretion standard. Id. We cannot say the trial court acted arbitrarily, capriciously, or unreasonably in excluding this item of Dr. Kroeger's testimony.