Opinion ID: 2514133
Heading Depth: 1
Heading Rank: 4

Heading: Necessity of Expert Testimony to Prove Negligence

Text: The standard of medical or hospital care which is to be applied in any given case is not a rule of law, but a matter to be established by the testimony of competent medical experts. Chandler, 223 Kan. at 5. In order for Audra to recover damages, she was required to prove all the elements of a medical malpractice case: (1) The physicians owed her a duty of care and were required to meet or exceed a certain standard of care to protect her from injury; (2) the physicians breached this duty or deviated from the applicable standard of care; and (3) she was injured and her injury proximately resulted from the physicians' breach of the standard of care. See Delaney v. Cade, 255 Kan. 199, 202-03, 873 P.2d 175 (1994). The question of whether a duty exists is a question of law. Glassman v. Costello, 267 Kan. 509, 521, 986 P.2d 1050 (1999). But negligence is never presumed, Schmidt v. HTG, Inc., 265 Kan. 372, 382, 961 P.2d 677, cert. denied 525 U.S. 964 (1998), and may not be inferred merely from a lack of success or an adverse result from treatment. [Citation omitted.] The plaintiff in a medical malpractice case bears the burden of showing not only the doctor's negligence, but that the negligence caused the [plaintiff s] injury. Bacon v. Mercy Hosp. of Ft. Scott, 243 Kan. 303, 307, 756 P.2d 416 (1988). Expert medical testimony is ordinarily required. Delaney v. Cade, 255 Kan. 199, 211, 873 P.2d 175 (1994). We believe the expert testimony requirement in medical malpractice cases is particularly apt in the current managed care environment, populated as it is by family practice gatekeepers and the specialists to whom they refer patients for care and from whom they receive referrals for more routine tests and procedures. We are aware this arena is not static. As a common-law court we need to turn a receptive ear to societal changes while safeguarding traditional tort concepts that exist to protect injured persons. Affirmance of the district court's Instruction No. 15 as written, with its relaxation of the expert testimony requirement, would cast a long precedential shadow of liability over health care providers, particularly those who function merely as links in a referral chain required by today's version of managed care. Existence and Parameters of Physicians' Duties to a Fetus Defendants acknowledge that a doctor owes a duty of care, i.e., must meet or exceed the standard of care applicable to a given patient, once he or she establishes a doctor-patient relationship. Dr. Donnell disputes the district court's holding as a matter of law that a physician who establishes a doctor-patient relationship with a pregnant woman who intends to carry to term also establishes a doctor-patient relationship with the fetus, particularly as applied to a referring primary care physician like himself. Drs. Moser and Brown do not deny they had duties to Audra; however, they argue their duties ended when their doctor-patient relationship with Bonnie terminated. The first portion of the district court's holding does not trouble us in the abstract. To the extent a pregnant woman desires to continue her pregnancy and deliver a healthy baby at its conclusion, her interest in receiving adequate health care is inevitably intertwined with any interest or potential interest of her fetus. In such a situation, the patient cannot be separated from her pregnancy nor her pregnancy from herself. We need not look beyond this incomparable relationship that is the genesis of the human condition. The mother who wishes to carry her pregnancy to term looks to her physician to guide her through her pregnancy, with the ultimate goal of the delivery of a healthy infant. Childbirth involves a universally recognized unique relationship between mother and child. Other jurisdictions have recognized the relationship between a physician and a pregnant patient and her fetus. See Hughson v. St. Francis Hosp., 92 App. Div.2d 131, 132, 459 N.Y.S.2d 814 (1983) (finding it is now beyond dispute that in the case of negligence resulting in prenatal injuries, both the mother and the child in utero may each be directly injured and are each owed a duty, independent of the other); Wheeler v. Yettie Kersting Memorial Hosp., 866 S.W.2d 32, 44 n.16 (Tex. Civ. App. 1993) (pointing out that Burgess v. Superior Court, 2 Cal. 4th 1064, 9 Cal. Rptr.2d 615, 831 P.2d 1197 [1992], noted the scope of duty owed by a treating physician to a pregnant woman extends to the fetus and includes a duty to avoid injury to the fetus). These decisions support our holding that a duty to the fetus exists in the abstract. The difficulty arises when we leave the abstract for the real world. Does a referring family practice physician such as Dr. Donnell have a doctor-patient relationship with Bonnieand thus Audrasufficient for a duty to arise? Do the duties Drs. Brown and Moser admit they have to Audra extend beyond the termination of their relationship to Bonnie? Does their knowledge of Bonnie's communicable disease and ways to minimize the risk of its transmission to Audra affect the answer? What are the parameters of the duty in such a situation? Where a communicable disease has been diagnosed in a pregnant woman who desires to continue her pregnancy to term and deliver a healthy baby, we agree with the district court that the woman's physician has an obligation as a matter of law to inform the woman of the diagnosis. See Annot., Malpractice: Failure of Physician to Notify Patient of Unfavorable Diagnosis or Test, 49 A.L.R.3d 501 pp. 507-512, and 2001 Supp. p. 43; see also Jacobs v. Theimer, 519 S.W.2d 846, 848 (Tex. 1975) (finding that a physician was under the duty to disclose to a pregnant woman that she had contracted rubella and to inform her of the risk of proposed treatment in continuing the pregnancy); Ray v. Wagner, 286 Minn. 354, 355-57,176 N.W.2d 101 (1970) (a routine Pap smear reported suspicious for malignancy; doctor tried to reach patient to report result but she had moved without notifying the doctor of a forwarding address, and she had no phone at her home; carcinoma of the cervix diagnosed; doctor had a duty to take whatever steps were reasonable to notify the patient of her test results; negligence and causation were jury questions; jury's verdict was for the doctor). Because a woman's interest in preventing the spread of a disease is intertwined with any interest or potential interest of her fetus at that point, this holding is consistent with the physician's tandem duty to the fetus. It is also philosophically consistent with decisions from other jurisdictions recognizing a doctor's duty to inform nonpatient third parties of infectious disease to prevent its spread. See Hoffman v. Blackmon, 241 So.2d 752, 753 (Fla. Dist. App. 1970), cert. denied 245 So.2d 257 (Fla. 1971) (finding the physician was liable for failing to warn family members that a patient with a communicable disease could infect them); Moreta v. New York City Health & Hospitals Corp., 238 App. Div.2d 149, 149, 655 N.Y.S.2d 517 (1997) (finding that physicians owed a duty to the unborn child, where medication was discontinued during pregnancy and resulted in the child's contracting tuberculosis from the mother); DiMarco v. Lynch Homes-Chester County, 525 Pa. 558, 561-63, 583 A.2d 422 (1990) (finding that under Restatement [Second] of Torts § 324A [1965], physicians owed a duty to the boyfriend of a hepatitis B carrier); Troxel v. A.I. Dupont Institute, 450 Pa. Super. 71, 83-84, 675 A.2d 314, rev. denied 546 Pa. 668 (1996) (finding that physicians have a duty to third persons and must correctly inform the patient about the contagious nature of the disease to prevent its spread to those who are within the foreseeable orbit of risk of harm); Bradshaw v. Daniel, 854 S.W.2d 865, 872-73 (Tenn. 1993) (finding the physician had a duty to warn identifiable third persons in the patient's immediate family of foreseeable risks associated with Rocky Mountain Spotted Fever). We also note that this court in Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093 reh. denied, 187 Kan. 186, 354 P.2d 670 (1960), expressed an interesting tangential observation on informing a patient. Natanson concerned an allegation of medical malpractice where the patient consented to treatment but claimed the nature and risks of cobalt treatment for cancer had not been explained to her. The Natanson court said: There is probably a privilege, on therapeutic grounds, to withhold the specific diagnosis where the disclosure of cancer or some other dread disease would seriously jeopardize the recovery of an unstable, temperamental or severely depressed patient. But in the ordinary case there would appear to be no such warrant for suppressing facts and the physician should make a substantial disclosure to the patient prior to the treatment or risk liability in tort. (Emphasis added.) 186 Kan. at 406. The other specific questions posed by this case are questions of fact that require further development of the record on retrial. Whether all or some of the physicians treating Bonnie failed to use the required care and diligence in discharging their duty to inform her of her hepatitis B status is to be decided with the aid of expert medical testimony. The jury should be guided by the language in PIK Civ.3d 123.01, Duty of Health Care Provider: In performing professional services for a patient, a [physician] has a duty to use that degree of learning and skill ordinarily possessed and used by members of that profession and of that school of medicine in the community in which the [physician] practices, or in similar communities, and under like circumstances. In the application of this skill and learning the [physician] should also use ordinary care and diligence. A violation of this duty is negligence. See also PIK Civ.3d 123.10 (expert testimony). The physician defendants will be free to argue that, once a pregnant patient is transferred to another doctor, the transferring doctor is governed by a different standard of care. Audra will be free to contend that a continuing duty existed to provide treatment and care to her while in utero and at the time of her birth. The jury will be free to decide whether the physicians were required to act to inform Bonnie throughout the period during which preventive steps could have been taken and whether a patient's primary care physician continues to be responsible for the well-being of the expectant patient and the patient's fetus, even when the patient is referred to an obstetrical specialist. PIK Civ.3d 123.12 relates to the duty of a medical specialist and PIK Civ.3d 123.13 covers the referral of a patient to another health care provider. (A ____ who undertakes the treatment and care of a patient and refers the patient to a ____ for treatment and care is not legally responsible for any negligence on the part of the ____ unless (he)(she) has failed to exercise reasonable care in selecting the ____) See Stovall v. Harms, 214 Kan. 835, 522 P.2d 353 (1974); accord 2 Louisell & Williams, Medical Malpractice ¶ 16.05(1) (2001) (liability for referrals). For example, Dr. Donnell proffered the testimony of Dr. David Kingfisher. Dr. Kingfisher, because of the district court's summary judgment ruling leading to Instruction No. 15, was not permitted to testify. Dr. Donnell's counsel said: In arguments in response to summary judgment motion of the plaintiff with respect to duty at that time I presented to the court the opinion of Dr. David Kingfisher and I would as a matter of judicial economy as well as overall economy proffer that. If he was called to testify he would testify as to the duty of Dr. Donnell and that Dr. Donnell's duty was met by properly transferring obstetrical care of Bonnie Nold to Dr. Moser and that the patient who is bringing this action, Audra Nold, under these circumstances was not the patient of Dr. Donnell and he was not in a position to protect her from the alleged injury. Expert witnesses should be permitted to testify on retrial for both sides to assist the jury in determining the contours of the doctor-patient relationship and resulting duty in a referral system. Dr. Moser's contention that he had no physician-patient relationship with Audra following her delivery, and Dr. Brown's evidence that he ended his doctor-patient relationship with Bonnie during the first trimester of her pregnancy, should also be considered by the trier of fact. The effect of the termination of Dr. Binyon's care by Bonnie also should be considered. Whether a doctor-patient relationship exists is generally a question of fact for the jury. Rule v. Cheeseman, Executrix, 181 Kan. 957, 964, 317 P.2d 472 (1957). A duty arises and liability may be imposed only for negligence occurring during the doctor-patient relationship. Again, expert medical testimony will assist the jury in resolving Audra's negligence claims under the standard of care owing to Bonnie and Audra during the existence of each of Bonnie's particular doctor-patient relationships.