Opinion ID: 2583948
Heading Depth: 1
Heading Rank: 8

Heading: Did the district court err in precluding the appellants' only other retained expert from offering opinions as to the standard of care?

Text: [¶ 17] Gary M. Green, M.D., was retained by the appellants as an expert to establish the standard of care for infectious disease practice in the emergency room setting. After graduation from Georgetown University School of Medicine, Dr. Green did an internship in internal medicine at the Medical Center of Delaware. He then finished his residency at St. Joseph's Hospital & Medical Center in Phoenix, Arizona. Next, he completed a fellowship in infectious disease at U.C.L.A. He is board-certified by both the American Board of Internal Medicine and the American Board of Infectious Diseases. At the time of trial, he was Sub-Chief of the Division of Infectious Diseases at Santa Rosa Kaiser Permanente Medical Center. [¶ 18] Dr. Green's medical residency included training in emergency medicine. During his infectious disease fellowship at U.C.L.A., Dr. Green also worked as an emergency room physician at West Los Angeles Kaiser Hospital. After working for a time at Cedars Sinai Medical Center, also in Los Angeles, Dr. Green was recruited to Casper, where he established a private practice and worked at the Wyoming Medical Center. [¶ 19] In Casper, Dr. Green consulted in the emergency room at Wyoming Medical Center almost daily. He also taught infectious disease recognition and treatment to family practice residents at the University of Wyoming Family Practice Residency Program. Dr. Green testified as follows in reference to his familiarity while in Casper with emergency room treatment of infectious diseases: Q. While you were in Casper did you become familiar with the standards of practice for a reasonable and prudent board certified emergency physician in connection with recognition of infectious diseases? A. Yes, I was. In fact, it is not much different from that for internal medicine and family practice. Q. Is it substantially similar? A. Yes. [¶ 20] Dr. Green moved from Casper to Eureka, California, in 1999. There, he was the sole infectious disease specialist in two counties, and he held privileges at three area hospitals. He attended regularly in the emergency departments of all three hospitals. In doing so, he became familiar with the standards of care applied to infectious disease patients in those emergency departments, which standards were the same as had been applied in Casper. In his current position at Santa Rosa Kaiser Permanente Medical Center, he teaches emergency medicine specialists how to evaluate and treat patients with sepsis: Q. Dr. Green, do you teach emergency medicine, board-certified emergency medicine physicians about sepsis? A. Yes, I do. Q. When was the last time you did that? A. The last lecture I gave to the ER department was within the last six months. A. And did you teach emergency medicine physicians about infectious disease at Wyoming Medical Center? Q. Yes, I did. A. Do you teach them what standards to apply in approaching  in evaluating, diagnosing, and treating patients presenting with fever, tachycardia, of potential infectious processes? A. Yes, that's a basic tenant [ sic ] for the lectures I give. Q. Is that part of your job duties as infectious disease chief at Santa Rosa Hospital? A. It is. Q. And have you done that  did you do that at Wyoming? A. I did. [¶ 21] After establishing Dr. Green's qualifications, the appellants' counsel began to inquire directly about the standard of care: Q. Are the opinions that you're giving today within a reasonable degree of medical probability? A. Yes, they are. Q. And is [ sic ] the standard of care opinions you're rendering today, are those based upon the standard of care for emergency medicine when the questions are in that area of focus? A. Yes, they are. Q. And when questions will be in the focus of infectious disease will the standard of care then be for that subspecialty? A. Yes, they will be. [¶ 22] Counsel then began to ask Dr. Green about the process known as differential diagnosis. At that point, the appellees' counsel interjected the following objection: MR. RUTLEDGE: Your Honor, I'm going to object to relevance and also as to qualifications. If this is intended to be standard of care testimony about the standards applicable to an emergency physician, Dr. Green does not qualify to give standard of care opinions about emergency medicine physicians. He's not in the same line of practice. [¶ 23] The district court's initial reaction was to overrule this objection on the ground that he does present some evidence that he has some experience in emergency rooms. The appellees' counsel was granted leave to voir dire the witness, however, during which the following exchange occurred: Q. But your only experience practicing as an emergency room physician was for about one year during your infectious diseases fellowship between '95 and '96; isn't that true? A. That's correct, sir. . . . Q. And your training is considerably different than for a family practice physician practicing in the emergency department, isn't it? A. My training is different from a family practice physician, that's correct. Q. And your training is considerably different from a board certified person who has gone through an emergency medicine residency program? A. Yes, my training is different from an ER trained physician. Q. You've never gone through the emergency medicine residency program? A. That's correct. . . . Q. You've gone through an internal medicine residency? A. That's correct. Q. And that's not required to practice emergency medicine, is it? A. No, it is not. . . . Q. You agree that ethically you should have recent and substantive experience in the field or line of practice about which you're testifying? A. That's correct, I do agree with that. Q. And your recent and substantive experience as an emergency physician is consulting only with emergency physicians as an infectious diseases specialist; isn't that true? A. That's correct. Q. Okay. And when you're working in the emergency department and since you've completed your fellowship, all the time you've spent working in the emergency department has been as an infectious diseases specialist, hasn't it? A. At Kaiser Santa Rosa, sir? Q. No, anywhere. A. Is that what you are asking? Q. Anywhere. A. There are times when I've done internal medicine call, but it is fairly minor, I would say less than 5 percent of my time. Q. But you haven't worked as an emergency physician in the emergency department since? A. Since West Los Angeles Kaiser, that's correct. THE COURT: What year was that '95? THE WITNESS: About '95, '96, Your Honor. Q. (BY MR. RUTLEDGE) And when you're consulted by emergency department physicians in the emergency department you're consulted not as an emergency physician but as an infectious diseases specialist, aren't you? A. That's correct. MR. RUTLEDGE: Your Honor, I renew my objection to Dr. Green testifying about the standard of care. He is not in the same line of practice. [¶ 24] At the conclusion of the voir dire examination, the district court held a sidebar conference in order to rule on the objection: THE COURT: Kent, I need to ask you a question. I think you quoted from the ethics standards. What do those standards say one more time? I think that  MR. RUTLEDGE: They say that you should have recent and substantive experience in the same line of practice. THE COURT: Experience. So the question is, does teaching from a perspective of infectious disease specialist count for emergency room experience? Mr. Pickering. MR. PICKERING: Well, Your Honor, the test is not that. The test is the statutory test found in the Wyoming statutes which requires only that a physician be substantially familiar with the standards of care of the area of practice, and he is. We're bound by the statutory requirements of the state legislature. THE COURT: I would imagine that the ethics of the medical profession have something to do with this decision, wouldn't you agree? MR. PICKERING: It may have. THE COURT: Which he would violate if I'm going to let someone violate his ethics from the stand. MR. PICKERING: He's not violating his ethics. THE COURT: Sure he is. He has an opinion that doesn't violate the ethical  MR. PICKERING: He's called to the emergency room three days a week not as an emergency room doctor. They said he's observed the same standard of care. THE COURT: Is this witness going to give opinions on causations [ sic ]? Is he? MR. PICKERING: Causation, yes. THE COURT: I'm going to sustain the objection on standard of care. [¶ 25] In discussing the first issue in this opinion, we noted that the plaintiff in a medical malpractice action must establish the applicable standard of care, generally through expert testimony. We also noted that, under W.R.E. 702, a witness may be qualified as an expert by knowledge, skill, experience, training, or education . . .. In addition to these general directives, Wyo. Stat. Ann. § 1-12-601 provides a specific burden of proof in medical malpractice cases: (a) In an action for injury alleging negligence by a health care provider the plaintiff shall have the burden of proving: (i) If the defendant is certified by a national certificating board or association, that the defendant failed to act in accordance with the standard of care adhered to by that national board or association; or (ii) If the defendant is not so certified, that the defendant failed to act in accordance with the standard of care adhered to by health care providers in good standing performing similar health care services. (b) In either paragraph (a)(i) or (ii) of this section, variations in theory of medical practice or localized circumstances regarding availability of equipment, facilities or supplies may be shown to contravene proof offered on the applicable standard of care. [¶ 26] The appellants find error in the district court's ruling on several grounds. First, they contend that Dr. Hrabal was not a board-certified specialist in emergency medicine, so they were not required to establish the standard of care adhered to by that national board. Second, they argue that Dr. Green, although also not a board-certified specialist in emergency medicine, established through his testimony that he was well-qualified to testify as to the standard of care adhered to by health care providers in good standing performing similar health care services, namely the diagnosis and treatment of bacterial infection in the emergency room setting. The appellants rely on Beavis ex rel. Beavis v. Campbell County Memorial Hosp., 2001 WY 32, ¶ 13, 20 P.3d 508, 513 (Wyo. 2001), where this Court recognized that the standard of care may be the same in certain instances across lines of practice. They also point out that not only did both Dr. Tredal and Dr. Green testify that the standard of care in recognizing infectious disease in the emergency room did not differ from one area of practice to another, but the appellees' own expert, Dr. Rosen, testified that there was no reason for Dr. Hrabal to consult with an infectious disease specialist because the infectious disease specialist has no more information than you do. [¶ 27] The appellants' third argument against the district court's ruling that Dr. Green could not testify about the standard of care is that the district court allowed the appellees' expert, Dennis L. Stevens, M.D., to give such testimony even though he had no real knowledge of the standard of care that should be applied in the attendant circumstances. The appellees designated Dr. Stevens as an expert to testify about the standard of care and to give opinions as to Dr. Hrabal's care and treatment of Armstrong. Like Dr. Green, Dr. Stevens is board-certified in internal medicine and in infectious disease. Dr. Stevens attended medical school and did his internship and residency at the University of Utah. He then completed two years of infectious disease training at Brooke Army Medical Center in San Antonio, Texas. He remained at that facility for some time as assistant chief of infectious disease. In 1979, he went to work at the Veteran's Affairs Medical Center, in Boise, Idaho. At the time of trial, Dr. Stevens was Chief of the Infectious Disease Service at the V.A. Center. His current practice involves the diagnosis and treatment of patients with a variety of infectious diseases, and he lectures on infectious disease to University of Washington medical students. Over the years, Dr. Stevens has authored numerous publications dealing with infectious disease. [¶ 28] Prior to trial, the appellants filed a motion in limine seeking to preclude Dr. Stevens from testifying about the standard of care. Citing to Dr. Stevens' deposition, they pointed out that the doctor has had no training in emergency medicine since his internship, that he has never practiced in a private hospital, and that he had not seen and was not familiar with any emergency medicine texts. In short, relying on W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, just as the appellees later would do in challenging Dr. Green, the appellants argued in their motion that there is no evidence that Dr. Stevens has any familiarity with the standard of care owed by emergency room specialists. [¶ 29] The motion in limine was argued during a pretrial conference. Ironically, the positions taken by the parties in regard to the motion were, for all intents and purposes, exactly the opposite of the positions they later took at trial in regard to Dr. Green. The appellants raised the following points in seeking to keep Dr. Stevens from establishing the standard of care: (1) he has had no training in emergency medicine; (2) he is not board-certified in emergency medicine; (3) he has no experience in emergency medicine; and (4) he has no familiarity with the emergency medicine standard of care, as required by Wyo. Stat. Ann. § 1-12-601. [¶ 30] In response, the appellees raised the following points: (1) Dr. Hrabal is not board-certified in emergency medicine, so Wyo. Stat. Ann. § 1-12-601 does not hold her to the standard of care for such a specialist; (2) Dr. Stevens is a preeminent expert in the field of infectious disease; (3) the question of causation, about which he can testify, is inextricably interwoven with the standard of care; and (4) he works in the emergency department about once a week dealing with internal medicine emergencies. [¶ 31] The reader will remember that the district court's initial reaction during the trial was to overrule the appellees' objection and to allow Dr. Green to testify because he does present some evidence that he has some experience in emergency rooms. This initial ruling is reflective of the district court's apparent perception at that time that, by combination of training and experience, Dr. Green was qualified under W.R.E. 702 to testify about the emergency medicine standard of care, and that Wyo. Stat. Ann. § 1-12-601 did not require testimony from a board-certified emergency medicine physician under the circumstances. The district court's pretrial analysis of the same issue as it involved Dr. Stevens is consonant with that same perception: THE COURT: What does he say? What does Dr. Stevens say? MR. PICKERING: He's going to say that Dr. Hrabal met the standard of care for an emergency physician. Dr. Stevens has never even held privileges at a private hospital. He's been either at the Army or the VA for 20, 30 years. THE COURT: He [d]oesn't have any familiarity with infectious  MR. PICKERING: With emergency medicine. THE COURT: Now, why does that matter in this case? MR. PICKERING: Well, Your Honor, because he's going to testify about standard of care. And the Wyoming statutes require[] that they  since she's board certified, or at least holding herself to that standard, that he have familiarity with the standards of care. THE COURT: What statute is that? MR. PICKERING: That's Wyoming 1-12-601. THE COURT: Is it constitutional? Isn't that a question of evidence for the Court? Is the legislature intruding into prerogatives  MR. PICKERING: It has been held constitutional in other states, been applied by the Supreme Court of Wyoming numerous times. He didn't even know the names of emergency text authors. He's never even looked at an emergency medicine textbook. He  so we don't think he can offer any opinions on standard of care. At his deposition I said, are you going to talk about  THE COURT: So a guy comes in with a broken leg in the emergency room, the doctor fails to diagnose it. MR. PICKERING: Right. THE COURT: Your position is that the orthopedic surgeon who knows something about broken legs but has no ER experience cannot tell us what ought to be done in the face of the broken leg? MR. PICKERING: I think that's probably true. THE COURT: I don't believe it. I can't believe that the law is so irrational. MR. PICKERING: Well, several cases sided along that way. THE COURT: The question is, why do you need a medical expert testimony in the first place? Case law says you need it because the jury can't speculate. They're not doctors. They need to be told what the standard of care is. So when faced with a condition of is it viral or is it bacterial, what is the relevance of the distinction between an ER doctor and an infectious disease doctor? I don't understand the difference. MR. PICKERING: Well, Your Honor, the other argument  THE COURT: You're trying to hold this ER doctor arguably up to standards involving infectious disease diagnoses. MR. PICKERING: No. We're trying to hold her to the standards of an emergency medicine specialist. THE COURT: I assume that's lower than an infectious disease specialist. MR. PICKERING: I would assume so, too. THE COURT: So someone who says that even though I know about the higher standard, she didn't even violate the higher standard. MR. PICKERING: That may be, but he doesn't even know what the standard of emergency medicine is. He doesn't do it. [¶ 32] After this exchange with the appellants' counsel, and after the appellees' counsel responded, the district court denied the appellants' motion to preclude Dr. Stevens' standard of care testimony. Interestingly enough, the district court's decision was announced directly upon the heels of the following statement from the appellees' counsel: I point out that Dr. Green, their infectious diseases expert, who hasn't practiced in the emergency room for years as an emergency room physician and has only very limited experience practicing in the emergency room, is going to offer standard of care opinions about Dr. Hrabal. [¶ 33] We are unable to discern from the record, for purposes of W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, any meaningful distinction between the qualifications of Dr. Green and the qualifications of Dr. Stevens. Both are board-certified in internal medicine and infectious disease, both had some training in emergency medicine early in their careers, and both consult weekly on infectious disease cases in the emergency room. While neither is board-certified in emergency medicine, the same is true of Dr. Hrabal. The record contains evidence that both are sufficiently familiar with the standard of care in treating infectious disease in the emergency room that their testimony would assist the jury in determining facts in issue. [¶ 34] The district court's reason for sustaining the objection to Dr. Green's testimony was that Dr. Green would be violating his professional ethics by testifying because he did not have recent and substantive experience in the field or line of practice about which he intended to testify. This justification fails for several reasons. First, the source of that ethical standard is not identified in the record. Second, there was no testimony from any medical professional that such testimony would violate the ethical standard. Third, Dr. Green's qualifications are such that he did have recent and substantive experience in the field or line of practice. Fourth, a medical expert's qualifications are determined under W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, not under some unidentified code of professional conduct. And finally, it goes without saying that if Dr. Green's testimony was, indeed, violative of his code of ethics, so likewise would have been the testimony of Dr. Stevens. [¶ 35] We hold that it was an abuse of discretion for the district court to preclude Dr. Green's standard of care testimony. No formal offer of proof was required to apprise the district court of the nature of the error and to preserve the issue for appeal because the substance of the precluded testimony was apparent from the circumstances. Further, the appellants were unfairly prejudiced by the ruling because the appellees' infectious disease expert was allowed to give standard of care testimony while the appellants' was not. This is especially troublesome in light of the jury's obvious difficulty in determining the standard of care by which they were to measure Dr. Hrabal's conduct.