Opinion ID: 1534917
Heading Depth: 2
Heading Rank: 1

Heading: Appellee Doctors.

Text: In support of their fraudulent-concealment argument, the appellants primarily rely on Howard v. Northwest Arkansas Surgical Clinic, P.A., 324 Ark. 375, 921 S.W.2d 596 (1996). In Howard , this court explicitly rejected the notion that any time a foreign object was left by a physician in a patient, the only exception to the two-year limitations period was the one year from discovery provision contained in Ark.Code Ann. § 16-114-203(b) (1987). Rather, we had recognized in past foreign-object cases that proof of knowing concealment was not always necessary to establish fraudulent concealment. Howard, supra (citing Faulkner v. Huie, 205 Ark. 332, 168 S.W.2d 839 (1943) and Burton v. Tribble, 189 Ark. 58, 70 S.W.2d 503 (1934)). The appellant in Howard had come forward with some evidence to support concealment of the fact that her treating physician had allowed the tip of a needle to remain in the patient's body with knowledge that it was there. Thus, the appellant's treating physician was not entitled to summary judgment based on the statute of limitations. In the case now before us there is an allegation of an act perpetrated in a way that it conceals itself. We have a defendant who had an obvious professional, positive duty to speak if he knew he had negligently left a foreign object in his patient, we have evidence that he was informed that the foreign object remained in the patient, and we have a plaintiff who could not, if the facts were as stated, have detected the fraud. Howard, supra . We emphasized that the General Assembly, in enacting the Medical Malpractice Act, could not have intended to allow physicians to avoid responsibility for negligent acts by knowingly concealing them from patients. By contrast, the radiologist who examined the tissue, and who had noted in her report to the treating physician that she had not seen the barbed tip of the needle in the tissue sample, was entitled to summary judgment as the appellant had not come forward with evidence to counter the radiologist's affidavit that she did nothing to conceal the fact that an object was left in the appellant. The doctors in turn emphasize Norris v. Bakker, 320 Ark. 629, 899 S.W.2d 70 (1995), another case where a physician's patient claimed that fraudulent concealment had tolled the limitations period on her causes of action. The patient in Norris alleged that her dentist had examined her breast under the pretense of a lymph node examination. While her complaint was filed outside of the limitations period, she argued that the dentist's act was something so furtively planned and secretly executed so as to keep her cause of action concealed from her because she lacked the essential medical knowledge to realize that the touching was not a necessary part of the examination. She also alleged that the dentist had a duty to inform her of the injury inflicted upon her in light of the physician-patient relationship. We affirmed the grant of summary judgment in favor of the dentist, given that the patient had failed to meet proof with proof to show that there was a genuine issue of material fact. In doing so, we emphasized the so-called classic language regarding fraudulent concealment: No mere ignorance on the part of the plaintiff of his rights, nor the mere silence of one who is under no obligation to speak, will prevent the statute bar. There must be some positive act of fraud, something so furtively planned and secretly executed as to keep the plaintiff's cause of action concealed, or perpetrated in a way that it conceals itself. And if the plaintiff, by reasonable diligence, might have detected the fraud, he is presumed to have had reasonable knowledge of it. Id. Id. (quoting Wilson v. GECAL, 311 Ark. 84, 841 S.W.2d 619 (1992)). In Norris , the patient simply failed to show how her dentist prevented her from learning that his representation was false. At the outset, we must reject the appellants' contention that in all informed-consent cases, there will always be genuine issues of material fact as to fraudulent concealment. The appellants assert in their reply briefs that within the context of informed-consent, fraudulent concealment will always occur when the evidence indicates that facts important to the Plaintiff's decision to undergo a particular treatment were fraudulently withheld, as in this case, from the plaintiff patient. While the appellants cite us to jurisdictions that might appear to go this far, we are unwilling to accept such a formulation of fraudulent concealment that would effectively eviscerate the two-year limitations period in all informed-consent cases. The Medical Malpractice Act establishes a two-year limitations period for medical injury, Ark.Code Ann. § 16-114-203(a), contemplates actions for lack of informed consent, see Ark.Code Ann. § 16-114-206(b)(1), and yet does not carve out an exception to the limitations period in informed-consent cases. Appellants' contention ignores the above-quoted classic language regarding fraudulent concealment and in fact obliterates any distinction between nondisclosure and fraudulent concealment in claims involving failure to obtain informed consent. To equate an alleged breach of a physician's duty to obtain a valid informed-consent with a fact question as to fraudulent concealment would effectively destroy the limitations period that begins running from the moment of medical injury. Here we are not concerned with the merits of the appellants' underlying claims, but instead we address whether their respective complaints were timely filed. In this regard, Trantafello v. Medical Ctr. of Taranza, 182 Cal.App.3d 315, 227 Cal.Rptr. 84 (Cal.Dist. Ct.App.1986) provides us with useful guidance. In Trantafello the plaintiff brought a medical malpractice action alleging that his surgeon had performed a surgical discectomy and had used a piece of an acrylic substance, methyl methacrylate, as a spacer in the spine where the disc was removed. The theory of the plaintiff's case was that the generally accepted practice in disc surgery was to implant a bone graft, and that the use of methyl methacrylate was an innovative procedure not generally accepted in the United States because of a high probability that it would not fuse or heal properly and which had a high incidence of pseudo arthrosis. The plaintiff alleged that prior to the surgery, the surgeon did not advise him that he intended to use methyl methacrylate instead of a bone graft, nor of the innovative nature and risks of the procedure. The plaintiff in Trantafello filed outside of the applicable limitations period under California law, but claimed that the limitations period should have been tolled by the defendants' intentional concealment. However, the Trantafello court emphasized that intentional concealment had to be something more than a mere continuation of the prior nondisclosure. While the opinion of the plaintiff's expert raised a factual issue as to whether the defendant's procedure was innovative, and whether the defendant was required to advise the plaintiff prior to obtaining the plaintiff's consent of the innovative nature of the operation and the available options and dangers involved, [i]ntentional concealment is something more than a lack of informed consent. It would have to have occurred either at or subsequent to the time that the medical procedure was undertaken. Id. Moreover, the plaintiff failed to show any issue as to an affirmative misrepresentation, as [p]laintiff conceded in his deposition that [defendant] never told him anything false about the surgery. [1] Id. In the present cases, we certainly agree that evidence of affirmative misrepresentations, either in connection with or subsequent to the appellants' surgeries, may create a fact question of tolling the limitations period for the jury. However, fraudulent concealment must go beyond a mere failure to obtain an adequate informed consent; it must rise to the level of some positive act of fraud, something so furtively planned and secretly executed as to keep the plaintiff's cause of action concealed, or perpetrated in a way that it conceals itself. See Norris, supra . Here, we note that Howard, supra , was a decision based on a foreign-object claim. The physician there had a duty to speak because he negligently left a foreign object in the patient, and there was evidence that the physician knew the foreign object was left in the patient. Such is not the case here, where these appellants knew that they were undergoing neck surgery requiring the implantation of some materialeither real bone or some synthetic material. Another case that bears mentioning is Roberts v. Francis, 128 F.3d 647 (8th Cir.1997). In Roberts the Eighth Circuit, interpreting Arkansas law, extended Howard beyond the realm of foreign objects to a case where the patient, who had her bladder removed to repair severe urological problems, also had her only remaining ovary removed without explanation. Basing its holding on the special nature of the doctor-patient relationship, the Roberts court held that the physician was under a duty to inform the patient that he had removed her only remaining ovarycreating a fact question as to fraudulent concealment. However, the fact situation presented in Roberts , where the patient consented to a urological surgery that resulted in the removal of her ovary without explanation, is much more like the Howard scenario than the present cases. The appellants here consented to neck surgery involving an implantation, which surgery they received, and the heart of these cases is whether or not that consent was informed. To simply say that in every informed-consent case the physician maintained primary control over the relevant information and the plaintiff [was] unaware of the alleged wrong, see Roberts, supra , ergo a fact question exists as to fraudulent concealment, is to do damage to the General Assembly's expression of public policy as embodied in the two-year limitations period. At the same time, we reject an interpretation of Norris that would foreclose a patient's ability to establish a fact question as to fraudulent concealment in all informed-consent cases involving alleged affirmative misrepresentations by the physician. While there is language in Norris that may be taken to that effect, [appellant] failed to show how [appellee] prevented her from learning that his representation was false[,] such an interpretation would lead to absurd results. It is easy to understand this quoted language based on the facts in Norris , where a dentist touched the patient's breast under the pretense of a lymph node examination. See also Howard, supra (patient in Norris knew the act had occurred); Roberts, supra (describing the patient in Norris as simply ignorant of her rights). Obviously, an affirmative misrepresentation by a physician in connection with or after the surgery may operate to conceal the patient's cause of action. See Jones v. Central Ark. Radiation Therapy Institute, Inc., 270 Ark. 988, 607 S.W.2d 334 (1980) (physician's representation concerning the uncertainty about the cause of plaintiffs' condition following medical injury and subsequent and purposeful dilatory conduct covered up its fraudulent character and prevented plaintiff from seeing another doctor. But for this fraud, [the plaintiff] could have discovered the alleged malpractice before the statute of limitations ran.) To hold otherwise would necessarily foster an environment of complete distrust between patient and physician. Such a consequence could not have been intended by the General Assembly in enacting the two-year limitations period. To the extent that there is evidence that the doctors' alleged omissions or misrepresentations resulted in a surgery performed without an adequate informed-consent, this obviously goes to the merits of appellants' claims. However, in examining whether appellants' complaints were timely filed, we reiterate that we do not simply equate evidence of a breach of the duty to obtain informed-consent with a fact question as to fraudulent concealment. There must be something more than a continuation of a prior nondisclosure. Rather, there must be evidence creating a fact question as to some positive act of fraud, something so furtively planned and secretly executed as to keep the plaintiff's cause of action concealed, or perpetrated in a way that it conceals itself. See Norris, supra . Finally, we must be mindful that an allegation of fraudulent concealment is not typically well-suited for summary judgment, unless the evidence leaves no room for a reasonable difference of opinion. See O'Mara v. Dykema, 328 Ark. 310, 942 S.W.2d 854 (1997); Chalmers v. Toyota Motor Sales, 326 Ark. 895, 935 S.W.2d 258 (1996). Bearing these principles in mind, we now turn to the proof submitted in these cases as abstracted.
The evidence submitted by the various appellants in response to the appellees' motions for summary judgment, including that which is abstracted, is not completely identical. In the three cases where AMI was named as a defendant, Adams, No. 96-1350, Stewart, No. 96-1405, and Beavers, No. 96-1470, the appellants submitted the same exhibits except for portions of the appellants' affidavits. Deposition testimony from Dr. Arthur established that Orthoblock had not been approved by the FDA for use in the human spine. Arthur also acknowledged that the long-term effects of the Orthoblock regarding such uses were not yet known. David Gassier opined in deposition testimony that he lacked sufficient data to give an opinion as a scientist as to whether hydroxylapatite could withstand the forces of the human spine based solely upon this one article. Use in the human spine was not an indicated use on the package insert that accompanied Orthoblock. A contraindication was that Orthoblocks should not be used where they would likely sustain significant tensile, flexural or shear forces. In answers to interrogatories, AMI contended that Arthur never sought specific approval of any hospital committee with respect to the use of Orthoblocks in cervical fusions, and that Arthur never informed it of such use. Once AMI became aware of the filing of this lawsuit, it had not used or ordered Orthoblocks. A Conditions of Admission is abstracted to show the Financial Agreement between the patient and the hospital. Arthur reported to Calcitek that he had very few fractures with Orthoblock, although Gocio had experienced a fracture rate of about 50%. Arthur attributed the higher rate to the force that Gocio used in tapping the Orthoblock into place. In a letter dated March 29, 1991, a Dr. Lawrence from the University of Marshall of San Diego informed Calcitek that he consecutively had two Orthoblocks fracture, causing him to express concern about the viability of Orthoblock. A Calcitek invoice to AMI, dated July 24, 1992, showed two separate quantities of Orthoblock, seven A-6, and three A-8, billed at $150 a unit. A St. Joseph's Product Return Receipt dated April 5, 1991, explained that a block broke off during surgery. No pressure [illegible] drills used according to OR. Credit on arrival please. An internal Calcitek complaint evaluation memo dated June 28, 1991, regarding the St. Joseph's complaint, resulted in the discovery that Orthoblock was used in an anterior cervical discectomy procedure. The block was tamped using a metal tool directly against the block. The memo further explains that Orthoblocks are not designed to withstand contact with metal tools. Calcitek sent Arthur and Gocio Custom Device Agreements in order to continue use of Orthoblocks in their practices. Custom seating tools had also been provided to assist them in placement of Orthoblock without using metal tools. The appellants in all twelve cases submitted affidavits. These affidavits identify the following as a partial list of facts that were never disclosed to me by Arthur, Gocio, the hospital, or anyone else prior to my surgery. Had these facts been disclosed to me, I would not have allowed the surgery to be performed with the product known by the tradename Orthoblock:  That he had experienced fractures with the product Orthoblock in other patients.  That the product Orthoblock was not FDA approved for use in human spines.  That the product Orthoblock was not designed by the manufacturer for use in human spines.  That the package insert that came with the product indicated that it was not designed for use in applications where it would undergo significant flexural, tensile, or sheer forces. These forces, of course, describe the types of movements and stresses that are in the spine.  That the use of the product Orthoblock in the human spine was experimental.  That the hospital's institutional review board that is charged with the review of such procedures had not reviewed or approved the use of the product Orthoblock in the spine.  That Dr. Arthur had only reviewed one article and discussed the use of the material known as Orthoblock with a dentist to determine whether it was safe for use in the spine. He did not tell me that the professional review at the end of that one article he had read called for more study before this product was used in the human spine.  That prior tests performed by the manufacturer with this material on mongrel dogs indicated that the material used in the product Orthoblock was not appropriate for use in the spine.  That dense hydroxylapatite, a ceramic material from which the product Orthoblock is composed, is more brittle than bone.  That bone will not grow into or through this product as it will with bone taken from a patient's own body or bone that is donated for this purpose. I was not told, that, at best, this material will only act as a spacer. I was not told that this procedure using the product Orthoblock was not the normal and customary material used in the anterior cervical fusion procedure.  That there was a risk of fracture of the ceramic material known as Orthoblock.  That if the product Orthoblock fractured, I would have to undergo another surgery.  That neither Dr. Arthur nor Dr. Gocio had ever discussed the use of product Orthoblock with any other doctor who had experience using it in the human spine to determine whether it was safe or how it could be used.  That I was not subsequently advised that Gocio or Arthur had to sign a custom device agreement, a document acknowledging that the product Orthoblock was not designed for use in the spine and requiring them to make assurance that patients were aware of this fact and obtain from them their informed-consent before the material was used, to be able to purchase and use the product known as Orthoblock.  That he did not tell me that he had subsequently signed an agreement with the manufacturer of the product to keep secret the information he had regarding the development of this product for use in the human spine.  That the manufacturer had not included in its application to the FDA to market the product Orthoblock a request for permission to promote them for use in the spine.  That other patients had the product fail resulting in fractures of the ceramic material.  That other patients, after implementation of the product Orthoblock, continued to experience, among other problems, arm pain, shoulder pain, neck pain, arm and hand numbness, and severe, frequent headaches.  That other patients, after implantation of the product Orthoblock, had experienced a sensation of having difficulty swallowing.  That he did not know or have a basis for knowing the long term [e]ffect of the product's use in the human spine. Finally, the appellants' affidavits also contain statements that are unique to each case.
In his affidavit, Adams stated that on March 8, 1990, Dr. Arthur, assisted by Dr. Gocio, performed the surgery on his neck. Adams filed his complaint on March 31, 1993. Prior to his surgery, he had met with Dr. Arthur to discuss the procedure. Adams had assumed that bone from his hip would be used, since bone from his hip was used in his last surgery. Dr. Arthur did not disclose to Adams that he was going to use Orthoblock in his surgery. The day after the surgery, Adams recognized that he had no incision on his hip. At his first office visit with Dr. Arthur, he asked him about this. Dr. Arthur showed him an x-ray, which revealed the Orthoblock. Dr. Arthur explained that this was a manmade material, made in England, and that it had the texture of a tennis shoe. He further stated that he had not had any slip and had not had any other problems with an Orthoblock. He additionally said that the Orthoblock had small holes that allowed it to fuse with bone. This evidence does raise a factual issue as to whether the procedure was innovative and experimental, and whether Drs. Arthur and Gocio were required to advise Adams prior to obtaining his consent, of the innovative nature of the operation and the available options and dangers involved. See Trantafello, supra at 87. However, we are unable to say that the doctors' alleged omissions in failing to so inform Adams, or the character of the representations the doctors actually made, rise to the level of some positive act of fraud, something so furtively planned and secretly executed as to keep the plaintiff's cause of action concealed, or perpetrated in a way that it conceals itself. See Norris, supra . Significantly, Arthur made no representations as to what sort of material would be used in the surgery. Adams later acquired knowledge that Orthoblock was used on the first office visit following surgery. While some of Arthur's statements were arguably misrepresentations about efficacy, i.e., he told me ... that he had not had any slip and had not had any other problems with an Orthoblock, it fuse[d] with bone, these statements do not rise to the level of affirmative representations sufficient to create a fact question as to fraudulent concealment. Based on the evidence submitted in the Adams case, we conclude that there exists no fact question as to fraudulent concealment, and affirm the grant of summary judgment to the appellee doctors.
On May 24, 1990, Arthur, assisted by Gocio, performed a surgical procedure on Randy Stewart's neck. Stewart filed his complaint on March 11, 1993. Prior to surgery, he met with Gocio to discuss the procedure. Gocio told him that rather than use bone from his hip, he would use an artificial bone, which was growing in his laboratory. Stewart was on pain medication at the time, and was not given any other options nor was anything else explained to him about the material. Here we have a different representation than that made in the Adams case. Gocio allegedly told Stewart that he would use an artificial bone  growing in his lab. We hold that this affirmative statement, an arguable misrepresentation as to the nature of the material to be used in the surgery, is at least sufficient to create a fact question as to fraudulent concealment. This constitutes proof leaving room for a reasonable difference of opinion as to whether the Stewarts' causes of action were fraudulently concealed. The summary judgment to the appellee doctors is reversed in the Stewart case and the case is remanded for further proceedings consistent with this opinion.
On December 11, 1989, Arthur performed a surgery on Orville Beavers's neck, and his complaint was filed on February 12, 1993. Prior to the surgery, he met with Arthur to discuss the procedure. Arthur told him that he would use bone from the bone bank. His wife had this surgery before and they used a hip bone. No options were offered to him and he was simply told that Arthur would use a bone from the bone bank. Arthur did not advise him of any risk. He did not learn that he had Orthoblock in his neck until after he saw a newspaper article in January of 1993, and he obtained his medical records. Here, Orville Beavers alleged that Arthur told him that he would use bone from the bone bank in his surgery. This is evidence of an affirmative act that would have prevented Beavers from learning the actual nature of the material used in his surgery. We, therefore, hold that this alleged misrepresentation is sufficient to create a fact question as to fraudulent concealment. Accordingly, we reverse the grant of summary judgment to the appellee doctors in the Beavers case, and remand for further proceedings consistent with this opinion. 2. Deborah Ann Johnson and John Johnson, No. 96-1355; Kenneth Mitchell and Jan Mitchell, No. 96-1406; Patricia Foshee and Carl Foshee, No. 96-1407; Carl and Priscilla Rae, No. 96-1408; Sheila Orrell and Tommy Orrell, No. 96-1409; Ludivinia Gallegos Miller, No. 96-1414; Phyllis Dexter, No. 96-1415. In addition to the evidence set forth above, appellants in these St. Joseph's cases submitted supplemental items of evidence in response to the appellees' motions for summary judgment. This included deposition testimony from Gayle Sanders, a nurse at St. Joseph's. According to Sanders, Arthur told her that St. Joseph's was going to be using Orthoblock as one of several hospitals around the United States that would be trying Orthoblock. At the time, she knew that Orthoblock had been approved by the FDA for use in dental applications, but that it had not been approved for use in the spine. She did not have any conversations with anyone about this non-approval because it was something we were already doing. It was just a new technique, and I didn't feel it was necessary. Sanders told her charge nurse to order the Orthoblock, telling her that it was a new product that they would be using. To her knowledge, Orthoblocks were not taken to the hospital's human subjects committee or institutional review board for purposes of use in the spine. She further explained that she was never present when Arthur or Gocio talked to a patient about using Orthoblock because it was done prior to surgery. At one time, the maintenance department revised an instrument to make it blunt for use with the Orthoblock. She also recalled that at one time Calcitek representatives came down to observe an Orthoblock surgery. Since the first lawsuit was filed, she was informed to bring the Orthoblock out of the operating room. Since then, it had not been ordered. A St. Joseph's memo dated February 8, 1993, set forth the approval process for submission of a research protocol to St. Joseph's Institutional Review Board (IRB). All proposals for research involving human subjects at St. Joseph's were required to be submitted to the IRB for review pursuant to Department of Health and Human Services regulations. This included research involving medical devices for non-approved applications. St. Joseph's business minutes, dated May 15, 1990, state that a conference call was conducted by the Institutional Review Committee at St. Joseph's Regional Health Center/AMI National Medical Center. This included approval for a protocol and informed-consent regarding clinical evaluation of a HAP Porous BiMetric Hip System to be used in an investigational hip prothesis study. A December 13 1991, St. Joseph's bill to a patient named John Hall included a charge for an Orthoblock at the price of $304.25. Terri Baker, Calcitek's director of marketing, wrote a letter dated April 17, 1991, to Arthur and Gocio following her observation of a surgery. The letter explains that Calcitek had discussed with its engineers about a tap for use with the block. We do have some preliminary ideas and should be able to get a prototype to you in the next thirty days. We will include the plastic tip! This should reduce the number of cracked blocks. Arthur and Gocio also executed confidentiality agreements with Calcitek on April 8, 1991, abstracted as follows: All information of a technical nature imparted to or learned by me during the course of my association with the company with respect to the business of the Company including but not limited to formulas, patterns, devices, processes, compilations of information, specifications, research and development, and inventions, improvements, and discoveries within the scope of paragraph 1, shall be deemed confidential and shall not be disclosed by me to anyone outside the employ of the Company unless such information has been generally available to the trade. Because federal law prohibited Calcitek from promoting uses other than those indicated, Calcitek had the doctors execute custom device agreements so that pursuant to federal law, Calcitek could provide Orthoblocks to individual doctors using them in anterior cervical discectomy procedures on a custom basis. Arthur and Gocio executed this form, which contained an acknowledgment that the doctors would adequately inform the patient prior to use of this CUSTOM DEVICE. The appellants also attached as exhibits some hand-written notes from someone at Calcitek regarding a conversation with Gocio. Among other things, the notes provide that Using Orthoblocks 1 yr.; 3-5/ week; No mods usedhas had fractures; Spreads vertebrae far enough to drop implant into place; no tapping (fear of fractures). Other notes regarding a phone interview with Gocio indicate that he had a lot of shatter prior to learning how to use. These appellants also submitted affidavits from two experts, Dr. Robert North, and Claudia Jean Beverly, regarding St. Joseph's failure to meet the appropriate standards of care for usage of Orthoblock at the hospital. Beyond the common allegations in the appellants' affidavits already set forth above, these appellants also made individual allegations concerning their respective surgeries.