Opinion ID: 2092456
Heading Depth: 1
Heading Rank: 1

Heading: Exclusion of Dr. Adler's Testimony

Text: The plaintiffs assert here on appeal that the trial justice abused his discretion by excluding Dr. Adler's testimony on an intractable assumption that Dr. Adler was not qualified to determine whether an earlier cesarean section would have saved the baby's life because such an opinion required an interpretation of obstetrical data and that Dr. Adler was not an obstetrician. The determination of whether to qualify and permit an expert witness to proffer an expert opinion relative to an issue in dispute is left to the discretion of the trial justice and this Court will not disturb that determination absent clear error or an abuse of that discretion. See Sheeley v. Memorial Hospital, 710 A.2d 161, 164 (R.I.1998); Richardson v. Fuchs, 523 A.2d 445, 447 (R.I.1987). Nevertheless, as this Court has also opined, To say, however, that the question is addressed to the trial justice's discretion does not mean that his ruling is not reviewable. What it does mean is that the ruling will be sustained provided the discretion has been soundly and judicially exercised, that is, if it has been exercised in the light of reason applied to all the facts and with a view to the rights of all the parties to the action,    and not arbitrarily or wilfully, but with just regard to what is right and equitable under the circumstances and the law. DeBartolo v. DiBattista, 117 R.I. 349, 353, 367 A.2d 701, 703 (1976). The state legislature, it must be noted, has enacted legislation purporting to curtail a trial justice's discretion in admitting expert testimony in medical malpractice actions. See G.L.1956 § 9-19-41. Section 9-19-41 provides, In any legal action based upon a cause of action arising on or after January 1, 1987, for personal injury or wrongful death filed against a licensed physician, hospital, clinic, health maintenance organization, professional service corporation providing health care services, dentists, or dental hygienist based on professional negligence, only those persons who by knowledge, skill, experience, training, or education qualify as experts in the field of the alleged malpractice shall be permitted to give expert testimony as to the alleged malpractice. In interpreting § 9-19-41, this Court has reasoned that the wording employed in the statute does not require that an expert must practice in the same specialty as the defendant to testify about the requisite standard of care. Buja v. Morningstar, 688 A.2d 817, 819 (R.I.1997) (per curiam); Marshall v. Medical Associates of Rhode Island, Inc., 677 A.2d 425, 426 (R.I.1996) (per curiam). We had said earlier, in Buja, 688 A.2d at 819, that, There is nothing in the plain and unambiguous language of § 9-19-41 that requires that before an expert testifies in a medical malpractice case, he or she must not only be an expert in the field where the alleged malpractice occurred, but must also practice in the same specialty as the defendant. Such an additional requirement is unnecessary and is in contravention to the General Assembly's clear intentions, as expressed in § 9-19-41. In Marshall, 677 A.2d at 426, we also had noted that the statute does not suggest that to qualify as an expert witness, the testifying doctor must be board certified or otherwise have training in the same medical specialty as the defendant-physician. Accordingly, this Court has rejected the contention that § 9-19-41 permits only an expert whose formal specialty is the same as that of a defendant-physician or whose specialty is precisely related to the medical issue in the case to offer an opinion on the appropriate standard of care. See, e.g., Sheeley, 710 A.2d at 165; Buja, 688 A.2d at 819. Indeed, in Sheeley, 710 A.2d at 165, we held that a board-certified obstetrician and gynecologist was competent and qualified to proffer an opinion about the standard of care for performance of a delivery procedure by a family medical doctor. In Buja, 688 A.2d at 818-19, we likewise concluded that an obstetrician could testify and give expert opinion in litigation against a family practitioner whose patient had given birth to an infant with birth defects caused by oxygen deprivation. In Marshall, 677 A.2d at 426-27, we had earlier vacated a directed verdict precipitated by the trial justice's preclusion of an opinion by a pediatric and family medical doctor about the standard of care for an emergency room doctor and internist in treating an animal-bite wound. Rule 702 of the Rhode Island Rules of Evidence also repudiates the notion that an expert witness must have the exact formal certifications as the defendant to proffer opinion testimony. Rather, Rule 702 states, If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of fact or opinion. In Flanagan v. Wesselhoeft, 712 A.2d 365, 369 (R.I.1998), a trial justice granted the defendant's motion in limine to prevent the introduction of expert testimony based upon the alleged inability of the expert to testify in regard to his knowledge of the standard of care for pediatric surgeons practicing in Rhode Island. [6] In reversing, we reasoned that an out-of-state board-certified pediatric surgeon should have been allowed to offer his opinion on the standard of care for a cervical node excision performed by an instate pediatric surgeon because both the doctor's board certifications and his extensive knowledge, skill, and experience in pediatric surgery should have presumptively permitted his testimony to be admitted at trial. Similarly, in Gallucci v. Humbyrd, 709 A.2d 1059, 1064-65 (R.I.1998), in the context of Rule 702, this Court determined that a board-certified orthopedic surgeon was competent and qualified to proffer an opinion about the standard of care for rehabilitative therapy performed by a physical therapist. Other courts have likewise seen fit to reject the contention made here by the defendants that a medical professional must possess the same formal certifications as a defendant to give expert opinion in a medical malpractice case. See, e.g., Pool v. Bell, 209 Conn. 536, 551 A.2d 1254, 1258 (1989); Fitzmaurice v. Flynn, 167 Conn. 609, 356 A.2d 887, 892 (1975); Letch v. Daniels, 401 Mass. 65, 514 N.E.2d 675, 677 (1987). In Pool, 551 A.2d at 1258, the Supreme Court of Connecticut held that a neurologist could testify and proffer an expert opinion on the duty of care required of a general surgeon in a medical malpractice action. In Fitzmaurice, 356 A.2d at 892, the Supreme Court of Connecticut also ruled that it was error for the trial court to exclude the proffered expert testimony of a surgeon specializing in breast cancer surgery about the standard of care for an obstetrician and gynecologist in diagnosing breast cancer. The Massachusetts Supreme Judicial Court, in Letch, 514 N.E.2d at 677, also held that an orthodontist could testify and proffer an opinion in a medical malpractice case involving a pedodontist. Accordingly, we have construed the wording of § 9-19-41 and Rule 702 both literally and liberally as intending to require only that the proffered expert possess adequate knowledge, skill, experience, or education in the same field as the alleged malpractice. See Flanagan, 712 A.2d at 369; Sheeley, 710 A.2d at 165. In defining what constitutes the field of alleged malpractice, this Court has looked largely to the nature of the patient's injury or to the nature of the procedure employed rather than to rigid classifications based solely on specialty certification. In Sheeley, we explained: The appropriate standard of care to be utilized in any given procedure should not be compartmentalized by a physician's area of professional specialization or certification. On the contrary, we believe the focus in any medical malpractice case should be the procedure performed and the question of whether it was executed in conformity with the recognized standard of care, the primary concern being whether the treatment was administered in a reasonable manner. Any doctor with knowledge of or familiarity with the procedure, acquired through experience, observation, association, or education, is competent to testify concerning the requisite standard of care and whether the care in any given case deviated from that standard. Sheeley, 710 A.2d at 166. Accordingly, this Court has consistently held that an expert's testimony on the appropriate standard of care must be admitted when the witness possesses prerequisite prior experience in the field of the alleged malpractice, regardless of his or her formal specialty or certifications. See, e.g., Sheeley, 710 A.2d at 166; Buja, 688 A.2d at 819. We have reasoned that an expert's lack of formal certification may go to the weight to be given the expert's opinion by the fact finder rather than to its admissibility and a trial justice should not bar such testimony ab initio. See Buja, 688 A.2d at 819 (citing Marshall, 677 A.2d at 426-27). In so doing we of course continue to require that any proffered expert witness must still first demonstrate to the trial justice his or her particular knowledge acquired through education or experience in the field of alleged malpractice. See, e.g., Buja, 688 A.2d at 819. As we noted in Marshall, 677 A.2d at 427, this Court requires that the proponent of [expert testimony] must still show the trial court that the so-called expert-witness has knowledge, skill, training, or experience in the same field as the alleged malpractice so that the expert's testimony can be genuinely helpful to the jury. We believe, as aptly noted by the Supreme Court of Connecticut in Fitzmaurice, 356 A.2d at 892, that: Recognizing the complexity of knowledge required in the various medical specialties, more than a casual familiarity with the specialty of the defendant physician is required. The witness must demonstrate a knowledge acquired from experience or study of the standards of the specialty of the defendant physician sufficient to enable him to give an expert opinion as to the conformity of the defendant's conduct to those particular standards, and not to the standards of the witness' particular specialty if it differs from that of the defendant. Although this Court has primarily considered the question of whether a proposed expert witness formally trained in a different specialty other than that of the defendant may testify in the context of evaluating the appropriate standard of care in a given case, we discern no reason to adopt a different rule when that same expert is expected to testify regarding causation. In this case, we conclude that the trial justice erroneously evaluated the competency of Dr. Adler as an expert based solely on the doctor's formal certifications and specialties. A review of Dr. Adler's otherwise knowledge, skill, experience, and education in the field of the alleged malpractice  meconium aspiration syndrome in fetuses and infants  clearly demonstrates that he was certainly qualified to give his opinion on the issue of causation. He had testified to having more than adequate qualifications to ascertain and proffer his opinion about whether an earlier performance of a cesarean section would have prevented or mitigated meconium aspiration, which might have saved the life of the plaintiffs' infant. That testimony revealed that the bulk of his current work involved treating newborns in the intensive care unit at a community hospital. He indicated that he had treated numbers of newborns stricken with meconium aspiration syndrome and that most of his consulting practice involved children born with birth injuries resulting from asphyxia. Although defense counsel argued persuasively that Dr. Adler could not ascertain precisely when the fetus's periods of asphyxia began or came to an end, the trial justice overlooked Dr. Adler's considerable past experience in reading and interpreting fetal heart monitoring strips and fetal pH readings in connection with determining the onset and nature of neurological injury. Such experience certainly should have permitted the doctor to determine and opine when, in his opinion, the decelerations generally occurred and when a change in the fetus's acid base status transpired and, consequently, to determine from that point in time when the fetus was at risk because of a decrease in oxygen flow. Although the trial justice expressed his apparent concern that a pediatrician would be unable to understand the fetal life of a baby and would usually defer to an obstetrician on such matters, a board-certified pediatrician by definition most certainly would possess adequate general knowledge to comprehend the fetus's development in utero in order to treat a newborn. Dr. Adler testified during the voir dire that there are occasions when a pediatrician is in fact called upon and required to assess the effects of asphyxia and meconium aspiration syndrome on a newborn, and that as a board-certified pediatrician he had been called upon to do so on numerous occasions. Not coincidentally, Dr. Barden, the plaintiffs' expert obstetrician, who earlier had testified for the plaintiffs, told the court and jury that he preferred to defer to a pediatrician to proffer the opinion whether an earlier cesarean section would have saved the plaintiffs' infant. In this case the trial justice appears to have arbitrarily concluded that a pediatric neurologist could not make a skillful interpretation of obstetrical data and only could speculate on matters related to causation. In doing so, he obviously overlooked Dr. Adler's particular and considerable experience in interpreting obstetrical data, including fetal heart monitoring strips and pH levels. In this case, the question of causation revolved around when meconium aspiration syndrome occurred and, consequently, the approximate time when it became necessary for the defendants to perform a cesarean section. Depending upon his or her training and experience, a board-certified pediatric neurologist might be more qualified than the average pediatrician or perhaps even the average obstetrician to answer questions of causation. A pediatric neurologist by definition deals with injuries to the central nervous system, including the brain, many of which result from oxygen deprivation. As Dr. Adler testified, many of his patients consisted of newborns with injuries resulting from birth asphyxia. That hands-on experience, when coupled with the doctor's qualifications as a board-certified pediatrician and especially as a board-certified pediatric neurologist, we conclude, would qualify him to testify about the cause of the infant's death in this case. We determine that the trial justice clearly abused his discretion and erred in refusing to permit Dr. Adler to proffer his expert opinion about what caused the death of infant Debar. We determine that error to have been so prejudicial to the plaintiffs' case as to constitute reversible error and to require a new trial.