Opinion ID: 201339
Heading Depth: 1
Heading Rank: 3

Heading: Causation and Standard of Care

Text: 17 To prove that the medical care she received from Dr. Walker was negligent under Arizona law — and thus was compensable under the FTCA 11 — appellant needed to show both a departure from a reasonable standard of care and proximate cause between his treatment and her injury. See Ariz.Rev.Stat. §§ 12-561-563 (Medical Malpractice Act); 12 Thompson v. Sun City Cmty. Hosp., Inc., 141 Ariz. 597, 608, 688 P.2d 605, 616 (1984) (emphasis omitted) (trier of fact must find for the defendant unless [it] find[s] a probability that defendant's negligence was a cause of plaintiff's injury.). The district court's findings that she satisfied neither of these obligations are reviewed for clear error. See La Esperanza de P.R., Inc. v. Perez y Cia. de Puerto Rico, Inc., 124 F.3d 10, 15-16 (1st Cir.1997) (bench trial findings of fact subject to clear error review); Fed.R.Civ.P. 52(a). We deem a finding clearly erroneous only when, after reviewing the entire record, we are `left with the definite and firm conviction that a mistake has been committed.'  García Pérez v. Santaella, M.D., 364 F.3d 348, 350 (1st Cir.2004) (quoting Anderson v. City of Bessemer City, 470 U.S. 564, 573, 105 S.Ct. 1504, 84 L.Ed.2d 518 (1985)(internal citation omitted)). 18 Appellant's task on appeal is thus daunting. She not only bears the initial burden of proving the probability of a link between negligent care by Dr. Walker and the severity of her breast cancer, but she also must firmly convince us that the district court's ruling against her was unsupportable. Our review of the record leaves us unpersuaded. 19 We begin with appellant's contention that the district court erred in finding that Dr. Walker's treatment did not fall below the standard of care reasonably expected of health care providers in similar circumstances. Appellant specifically claimed that Dr. Walker should have pursued more testing to evaluate the persistent lump in her breast, ordering either a targeted ultrasound or fine needle aspiration. The record, however, contains ample evidence to support the court's determination that, with respect to breast lumps as small as appellant's, these techniques were not sufficiently effective in the early 1990s that they were a mandatory element of reasonable care. The court cited the testimony of Dr. Susan Pories, a breast cancer surgeon at Beth Israel Deaconess Medical Center (Beth Israel), who explained that ultrasonography was generally incapable of visualizing a mass of less than two centimeters in diameter and that fine needle aspiration of a mass as small as appellant's at the time Dr. Walker treated her (i.e., four to six millimeters) would have been close to impossible. 20 That view was reinforced by other testimony. Dr. Janet Baum, a radiologist and Director of Breast Imaging at Beth Israel, testified that ultrasound was just beginning to be used in 1991, and that she would not have recommended its use for such a small lesion because, even if the lesion were visible, you really couldn't evaluate it adequately. Appellant's expert, Dr. Houlihan, a breast surgeon and Director of the Breast Care Program at Beth Israel, acknowledged that performing fine needle aspiration on a mass of that size technically can be difficult. 21 Appellant contends that the court's conclusion on the standard of care is flawed because the court failed to consider the history of the growth of her breast mass, a progression that should have informed the standard of care and required the employment of additional diagnostic procedures. Dr. Walker did not ignore the implications of appellant's history, however, having recommended another mammogram and further evaluation six months following appellant's last appointment with him. Appellant did not return to Dr. Walker, and the record indicates that a mammogram was not done again for three years. 13 22 In sum, the district court's conclusion, based on expert testimony, that the small size of the mass rendered ultrasound and fine needle aspiration of doubtful value, combined with Dr. Walker's articulated intent that appellant and her doctors remain watchful, does not permit us to term clearly erroneous the court's finding that Dr. Walker did not deviate from the applicable standard of care. 23 That conclusion on standard of care effectively disposes of the case. Appellant's theory of recovery is that Dr. Walker should have done more investigation, which would have revealed the non-benign nature of the small mass in her breast; with such early detection, appellant claims she would have avoided the more serious cancer and risk of death that subsequently occurred. Without a finding that Dr. Walker negligently treated appellant, however, we need not consider the causal link between his care and appellant's injury. Even if the lump Dr. Walker palpated in July 1991 was the source of the cancer found in her right breast in 1995, there is no medical malpractice and no recovery if Dr. Walker's diagnostic approach reflected the degree of care, skill and learning expected of a reasonable, prudent health care provider in similar circumstances. Ariz.Rev.Stat. § 12-563. 24 We nonetheless choose to address briefly the district court's finding — intensely debated by the parties on appeal — that appellant fell short of proving that the cancerous lump detected in 1995 was the same mass, in an early stage, encountered by Dr. Walker. The district court cited as crucial the testimony offered by Dr. O'Donnell, the surgeon who performed appellant's mastectomy. Dr. O'Donnell, who had reviewed appellant's medical history, testified that he was unable to say whether there was a connection — or not — between the earlier lump and the tumor he removed. 25 Dr. O'Donnell's testimony that the medical indicators were inconclusive was balanced on either side by the appellant's and the government's experts. Testifying for appellant, Dr. Houlihan stated that a relationship between the two masses was indicated by the similarity in location. The government's experts, meanwhile, opined that the post-operative pathology reports showed a rapid growth rate for the excised tumor, suggesting that it was of more recent development. Dr. Connolly, Chief of Anatomical Pathology at Beth Israel and the expert whose testimony appellant had sought to counter with Dr. Smith's excluded evidence, concluded that the tumor likely was doubling in size every thirty days — a rate too fast for the two masses to be related. Supporting the theory that the cancer was of more recent origin, Dr. Baum testified that her review of appellant's 1989 and 1991 mammograms did not reveal any abnormal masses. In response to the rapid growth theory, Dr. Houlihan testified, essentially, that one cannot work backward from the tumor itself to know how long it was there, Galgano, 329 F.3d at 245, and noted that these tumors will frequently change their behavior during their lifespan. She acknowledged, however, that the tumor was very fast-growing... at the time that it was removed. 14 26 The district court ultimately found the government's scenario to be more persuasive, noting among other reasons that Dr. Houlihan's opinion was based on less than the full medical record. 15 The court also found particularly telling Dr. O'Donnell's testimony that the lesion he removed was deep in appellant's breast. Dr. Walker testified that the mass he had palpated was superficial, and his recollection of the location of the lump was substantiated by Dr. Houlihan's testimony that palpating a mass less than one centimeter in diameter can be difficult if it is not near the surface of the breast. 27 In short, as we read the record, both sides offered cogent evidence in support of their positions through the testimony of highly qualified medical experts, all of whom were colleagues at the same hospital. We see no clear error in the district court's judgment that the government's experts were, on the whole, more persuasive. Although Dr. Connolly's testimony about the growth of the tumor factored into the court's analysis, we cannot accept the notion that exclusion of appellant's proposed rebuttal witness was decisive. As described above, Dr. Connolly was only one of multiple experts who offered opinions cited by the court negating the link between the mass palpated by Dr. Walker and the cancerous tumor that was found three years later. And, as counsel had predicted, Dr. Houlihan effectively responded to Dr. Connolly's suggestion that the post-operative pathology inevitably meant the two lumps were unrelated. 28 Even if Dr. Walker's treatment had constituted a breach of the applicable duty of care, and even if we deemed the battle of the experts a draw on the issue of causation — in our view, the best case for appellant supported by the record — the government would prevail in light of appellant's burden to show a probability of harm from Dr. Walker's treatment. Accordingly, we find no basis upon which to disturb the district court's judgment. 29 Affirmed.