Opinion ID: 2382084
Heading Depth: 2
Heading Rank: 2

Heading: The Physicians' Records

Text: In the P.A.'s consultation note dictated on May 29, 1996, based on an examination of May 22, the clinical impression as of the date of that examination was that Shpigel sustained acute musculoligamentous strain injury of the supporting structures of the cervical spine. The medical history segment of the initial consultation note advises that Shpigel was involved in a motor vehicle accident one year ago in which he injured his neck but from which he recovered without sequelae and that [h]e had been followed through this office for that injury as well. Shpigel's purpose in proffering the P.A.'s records concerning his examinations, his visits for physical therapy, and the disability certificates is to prove that he was totally disabled from May 22 through June 17, 1996, with resulting economic and non-economic damages. In order to fall within the Rule 5-803(b)(6) exception to the hearsay rule the evidence must be trustworthy. Further, relevant evidence may be excluded if its probative value is substantially outweighed by the danger of ... confusion of the issues, or misleading the jury. Rule 5-403. Here, the causal connection between the accident of May 21, 1996, and the damages claimed by Shpigel presents a somewhat complicated medical question on which expert testimony is required in order to support a finding that the accident of May 21, 1996, caused a total disability. The seminal case in this state is Wilhelm v. State Traffic Safety Commission, 230 Md. 91, 185 A.2d 715 (1962). There we held that expert testimony was required in order to establish a causal nexus between a motor vehicle collision and emotional disturbances in [the plaintiff] sufficient to evoke, subconsciously, grossly exaggerated symptoms. Id. at 101, 185 A.2d at 719. Expert testimony was also required to establish a nexus between the accident and abdominal and back pains associated with the [plaintiff's] menses. Id. No expert testimony, however, was required in order to prove the nexus between the accident and a loss of pigmentation on the plaintiff's forehead at the site where her head struck a sun visor in the accident and where she had a bruise for some three or four months. Id. at 103,185 A.2d at 721. Maryland appellate cases on this issue have recently been reviewed for the Court of Special Appeals by Judge Thieme in Hunt v. Mercy Medical Center, 121 Md.App. 516, 538-42, 710 A.2d 362, 373-75 (1998), and by Judge Moylan in S.B. Thomas, Inc. v. Thompson, 114 Md.App. 357, 376-81, 689 A.2d 1301, 1310-13 (1997). Although recognizing that these cases are fact specific the court in S.B. Thomas undertook a distillation, saying: A genuine jury issue as to the causal relationship between an earlier injury and a subsequent trauma may sometimes be generated, even in the absence of expert [medical] testimony, when some combination of the following circumstances is present: 1) a very close temporal relationship between the initial injury and the onset of the trauma; 2) the manifestation of the trauma in precisely the same part of the body that received the impact of the initial injury; 3) as in Schweitzer v. Showell, [19 Md.App. 537, 313 A.2d 97 (1974),] some medical testimony, albeit falling short of a certain diagnosis; and 4) an obvious cause-and-effect relationship that is within the common knowledge of laymen. Id. at 381-82, 689 A.2d at 1313. In this case there is no obvious cause-and-effect relationship between the accident and the claimed total disability that is within the common knowledge of laymen. Here, the issue is whether the records of the P.A., in and of themselves, are admissible to supply the necessary medical opinion. The same factors that underlie the holdings on the need for expert medical testimony on causation are also relevant to whether that expert testimony is to be presented through a live witness or through a business record. In this case the records of the P.A. reflect that Shpigel previously suffered a neck injury, and White contests the opinion, expressed in the records of the P.A., that there are no residual symptoms from that prior injury. The instant case also involves issues of the degree of force of the trauma, and there is a conflict between the P.A.'s opinion of a total disability of several weeks duration and the prognosis of three days discomfort made in the hospital discharge instructions. Although Maryland Rule 5-803(6) is not verbatim Fed.R.Evid. 803(6), the changes in the former from the latter are intended to be nonsubstantive. L. McLain, Maryland Rules of Evidence, at 245 (1994). The editors of 5 Weinstein's Federal Evidence § 803.11[7][a], at 803-76 through 803-77 (2d ed.1999), in addressing the type of issue now before us, state that [i]f the expert is available and the diagnostic opinion is of a kind competent physicians may disagree upon, the judge has discretion to require the expert to testify to insure trustworthiness through cross-examination, particularly if the medical issue is crucial. (Footnote omitted). In Owens-Illinois, Inc. v. Armstrong, 326 Md. 107, 604 A.2d 47, cert. denied, 506 U.S. 871, 113 S.Ct. 204, 121 L.Ed.2d 145 (1992), this Court described the factors that could lead to a determination that a business record is untrustworthy. We said: The factors that can be utilized by a trial judge in determining whether a business record or a portion of a business record should be excluded for lack of trustworthiness may include such factors as: 1) the purpose for which the record was prepared and any possible motive to falsity including whether the record's use in prospective litigation was a motive for its preparation; 2) how routine or non-routine the record is and how much reliance the business places on the record for business purposes; and 3) where, as in the instant case, the record contains opinions and conclusionshow valid, speculative, or conjectural the opinions or conclusions are, as well as the need for interpretation or cross-examination to prevent misleading or confusing the trier of fact. Id. at 115, 604 A.2d at 50-51 (citations omitted). Somewhat analogous to the instant matter is Chadderton v. M.A. Bongivonni, Inc., 101 Md.App. 472, 647 A.2d 137 (1994). Chadderton was a workers' compensation case in which the insurer and the Subsequent Injury Fund succeeded in placing in evidence in the circuit court copies of the reports rendered to them by the physicians to whom they had referred the claimant for the purpose of obtaining an opinion on the nature and extent of disability. Closely following the analysis in Yates v. Bair Transport, Inc., 249 F.Supp. 681 (S.D.N.Y.1965), the Court of Special Appeals held that the reports were inadmissible. Yates was a motor vehicle accident case involving a plaintiff who had previously made a workers' compensation claim. The plaintiff sought a pretrial ruling on the admissibility of medical reports rendered by his treating physicians in the then pending accident case and by physicians who had examined him for the insurer in the workers' compensation case and for the insurer of the defendant in the motor vehicle accident case. Id. at 689. There was a stipulation that the reports were authenticate, and the court concluded that they were regularly maintained business records. The Yates court then addressed the concern noted in Palmer v. Hoffman, 318 U.S. 109, 63 S.Ct. 477, 87 L.Ed. 645 (1943), with the likely untrustworthiness of materials prepared specifically by a prospective litigant for courtroom use. Yates, 249 F.Supp. at 689. The court in Yates looked for an added element of trustworthiness which will counterbalance the fact that these reports were prepared in clear anticipation of litigation. Id. at 689-90. That added element of trustworthiness was found in those reports that were rendered by physicians to whom the plaintiff had been referred by the defendant, and the Yates court ruled that it would admit those reports. On the other hand, the court would not admit those reports rendered by the plaintiff's treating physicians, saying: No case, however, has been found or cited wherein a plaintiff was permitted to introduce self-serving reports made by doctors of his own choosing, in anticipation of litigation to shore up his own case. Id. at 691 (footnote omitted). The Court of Special Appeals in Chadderton, applying the Yates rationale, held that the reports rendered by physicians to whom the claimant had been referred by the workers' compensation insurer and the Subsequent Injury Fund were not admissible when introduced by the parties who had arranged for those reports, essentially for a lack of trustworthiness. Chadderton, 101 Md.App. at 483-84, 647 A.2d at 142. Erroneously admitting the reports was held to be prejudicial, because the plaintiff was unable to cross-examine the physicians whose opinions were introduced in report form. Id. at 486, 647 A.2d at 144. Thus, although the circuit court in Chadderton had been persuaded that the reports were admissible under a section of the Workers' Compensation Act stating that `the proceedings in an appeal shall be informal and summary,' id. at 479, 647 A.2d at 140, and although the circuit court had found the reports to be sufficiently trustworthy, the Court of Special Appeals focused only on the trustworthiness aspect of that ruling. The appellate court in effect held that the circuit court had abused its discretion in concluding that the reports were trustworthy. Much the same problem was presented in Kelly v. HCI Heinz Construction Co., 282 Ill.App.3d 36, 218 Ill.Dec. 112, 668 N.E.2d 596, appeal denied, 169 Ill.2d 569, 221 Ill.Dec. 439, 675 N.E.2d 634 (1996). Kelly, a bricklayer, was injured in the collapse of a scaffold on which he was working. Under the Illinois Structural Work Act he sued the general contractor and the company which had supplied the scaffolding. At trial Kelly unsuccessfully sought to introduce as business records the records of his attending physician and the records prepared by a physician to whom the scaffolding supplier had referred Kelly. The appellate court sustained both exclusions. The treating physician's records were excluded as records prepared in anticipation of litigation and not made in the regular course of business. Id. 218 IlLDec. 112, 668 N.E.2d at 600. The same objection applied to the report by the defense expert, but those records may nevertheless be admissible against a party as an admission. Id. The Illinois court then summarized a portion of 2 J.W. Strong, McCormick on Evidence § 293, at 281 (4th ed.1992). The full text of the cited portion of that commentary, dealing with diagnostic statements in hospital records, is as follows: However, admissibility of all such entries is not assured. First, where there are indications of lack of trustworthiness, which may result from a lack of expert qualifications or from a lack of factual support, exclusion is warranted under the rule. Moreover inclusion of opinions or diagnoses within the rule only removes the bar of hearsay. In the absence of the availability of the expert for explanation and cross-examination, the court may conclude that the probative value of this evidence is outweighed by the danger that the jury will be misled or confused. This is of particular concern if the opinion involves difficult matters of interpretation and a central dispute in the case, such as causation. Under these circumstances, a court operating under the Federal Rules, like earlier courts, is likely to be reluctant to permit a decision to be made upon the basis of an un-cross-examined opinion and may require that the witness be produced. Id. (footnotes omitted). The Illinois appellate court held that [t]he trial court could properly have concluded that the opinions of [the defense expert] were important enough that they should be presented by live testimony, rather than in the form of medical records. Kelly, 218 Ill.Dec. 112, 668 N.E.2d at 600. In the matter now before us the factors considered by the cases and commentators reviewed above are present. Although the P.A. records were not so clearly prepared for litigation as are medical reports rating a claimant for workers' compensation benefits, nevertheless, the issuance by the P.A. of total disability certificates to Shpigel, who is self-employed, and who was on a personal trip when the accident occurred, suggests that litigation considerations were recognized in conjunction with the medical treatment. Further, the subject matter of the P.A. records are central to the litigation, the opinions contained therein are contested, as indeed is the necessity for the treatment, and the conflict with the prognosis of the emergency room discharge instructions evidences that White's insistence on the opportunity to cross-examine is not without foundation. Consequently, we hold that the circuit court acted within its discretion in ruling that the P.A. records would not be admissible. This discretion is conferred by the trustworthiness requirements of Rules 5-902(a)(11) and 5-803(b)(6), as well as by the trial judge's discretionary power conferred by Rule 5-403 to exclude evidence if its probative value is outweighed by the danger of misleading the jury. The findings in Dr. Stambler's reports to plaintiffs' counsel, based on his examinations of Benjamin and Daniela, are essentially negative. They report that each child was obviously frightened, and cried immediately after the accident and that each child slept well that evening, experienced no vomiting, but complained of frontal headache. We infer that Dr. Stambler's report was proffered in order to evidence the reasonableness or necessity of Shpigel's engaging a psychologist to examine and treat the children. Viewed from this light, there was no error in excluding Dr. Stambler's reports because there is no report from the psychologist and Dr. Stambler's reports do not recommend any psychological consultation.