Opinion ID: 1912527
Heading Depth: 1
Heading Rank: 3

Heading: Iowa's Medical Malpractice Statute.

Text: Iowa Code section 614.1(9) is the statute of limitations governing medical malpractice cases. Under section 614.1(9), medical malpractice claims arising out of patient care must be brought within two years after the date on which the claimant knew, or through the use of reasonable diligence should have known . . . of the existence of, the injury . . . for which damages are sought. Iowa Code § 614.1(9). As discussed at length in Rathje v. Mercy Hospital, 745 N.W.2d 443 (Iowa 2008) (filed today), the legislature's enactment of section 614.1(9) implemented a statute of repose for medical malpractice cases and addressed our holding in Baines v. Blenderman, 223 N.W.2d 199 (Iowa 1974), that the statute of limitations for medical malpractice cases began to run when a cause of action is discovered. Our holding in Rathje clarifies our application of section 614.1(9). The statute of limitations for medical malpractice cases is triggered upon actual or imputed knowledge of both the injury and its cause in fact. Rathje, 745 N.W.2d at 461. Knowledge of the wrongfulness of the defendant's conduct, however, is not required to commence the statute of limitations. Id. In granting summary judgment in this case, the district court concluded that, [o]nce Murtha was aware that a problem existed, a lump in her left breast, she had a duty to investigate even though she may not have had knowledge of the nature of the problem. . . . In this case, Murtha's lawsuit was filed on September 5, 2003. There is no dispute of material fact when viewed in the light most favorable to Murtha, that she had inquiry notice of her symptoms of her injury long before September 5, 2001 [the beginning of the two-year period preceding the filing of this suit]. Murtha's own deposition testimony reveals that the lump never went away and that she was always concerned about what it was from the time of its discovery. Thus, the knowledge of the physical harm occurred in 1997 and she was urged to have the lump removed as early as 1998. Murtha's knowledge of the injury was over five years prior to the filing of this lawsuit, therefore her claims are barred by the applicable statute of limitations. Section 614.1(9) does not support the ruling of the district court that the statute of limitations began to run in 1997 when Murtha first noticed the lump in her breast. Under that section, suit must be brought within two years after the date on which the claimant knew, or through the use of reasonable diligence should have known, . . . of the existence of, the injury . . . for which damages are sought. Iowa Code § 614.1(9) (emphasis added). The defendants contend that Murtha's injury was the lump she discovered in 1997. Further, they argue Murtha knew of the injury when she discovered the lump, was concerned about it, and knew it could be a sign of breast cancer. Murtha counters that she did not suffer an injury until she was diagnosed with cancer. It was only after her diagnosis, she argues, that she knew of her injury, thus triggering the beginning of the limitations period. As discussed below, we do not agree with either party's argument as to when Murtha suffered an injury for section 614.1(9) purposes and when she knew, or should have known, of such injury. Injury under the statute may occur at some point between the discovery of the lump (under the defendants' argument) and the final diagnosis of cancer (under the plaintiff's argument). Section 614.1(9) does not define the term injury. In fact, in medical malpractice cases, the term has been subject to considerable debate. It has been said that [i]njury could mean the allegedly negligent act or omission; the physical damage resulting from the act or omission; or the legal injury, i.e., all essential elements of the malpractice cause of action. Massey v. Litton, 99 Nev. 723, 669 P.2d 248, 250 (1983). In Schlote we defined injury, for purposes of section 614.1(9), as the physical harm incurred by the plaintiff, not the legal harm or wrongful act by the defendant. Today, we supplement that definition by including an additional requirement that the statute of limitations is only triggered upon knowledge, or imputed knowledge, of the cause in fact of the physical or mental injury. Rathje, 745 N.W.2d at 458. Thus, determining when the statute of limitations is triggered in a medical malpractice case requires two distinct steps. First, the plaintiff must have knowledge, or imputed knowledge, of an injury, i.e., physical or mental harm. Second, the plaintiff must have knowledge, or imputed knowledge, of the cause in fact of such injury. It is the first stepwhether the plaintiff knew, or should have known, she suffered an injurythat is at issue in the present case. For most medical malpractice cases, such as Schlote, defining injury as physical or mental harm is appropriate. However, claims of negligent misdiagnosis, as in the present case, are often based on a different type of harm and require us to further develop our definition of injury for such cases. See St. George v. Pariser, 253 Va. 329, 484 S.E.2d 888, 891 (1997) (recognizing that a different approach is necessary to determine the existence of an injury in misdiagnosis cases as opposed to malpractice actions based on the affirmative conduct of the defendant). In many medical malpractice cases, the injury for which damages are sought is immediately apparent. See, e.g., Christy v. Miulli, 692 N.W.2d 694, 699-700 (Iowa 2005) (plaintiff was immediately aware of the injurydeathupon the death of the deceased); Langner, 533 N.W.2d at 518 (patient was immediately aware of her injuryemotional and mental stressupon hearing the defendant's harmful statements). In those cases, it is relatively simple to determine what the injury is, when it occurred, its cause in fact, and when the plaintiff knew, or should have known, of itall of which occurred at the same time. Application of section 614.1(9) to such cases is straightforward. However, there are those medical malpractice cases that are based on an injury that is not immediately apparent, such as an internal condition with no specific external symptoms or a progressive condition. In such cases, it is not at all clear at what stage the ultimate injury for which the plaintiff seeks damages actually occurred, nor is the cause of such injury always clear. Rathje, 745 N.W.2d at 449. Expert testimony and other medical evidence are usually required to make these determinations. See, e.g., Renner v. Stafford, 245 Va. 351, 429 S.E.2d 218, 220-21 (1993) ([T]he crucial question in cases like this, when the date of the wrongful act possibly does not coincide with the date of the resulting harm to the plaintiff, is: When was the plaintiff hurt? The answer to this question must be found mainly in the medical evidence.). Further, determining when the plaintiff knew, or should have known, of the existence of the not-immediately-apparent injury, for statute-of-limitations purposes, is far from straightforward. Such cases often involve a claim of negligent misdiagnosis, as is the case here. Because, prior to today, we have not addressed how section 614.1(9) applies to a claim of negligent misdiagnosis in which the injury for which damages are sought is not immediately apparent, we look to other jurisdictions for guidance. Though the statutes of limitations in these jurisdictions are not necessarily identical to our section 614.1(9), they all require the fact finder to determine the stage at which the injury occurred and, as such, are instructive in identifying the injury and when it occurred in the context of a negligent misdiagnosis case. In DeBoer v. Brown, 138 Ariz. 168, 673 P.2d 912 (1983), the Arizona Supreme Court addressed facts very similar to those in this case. The Arizona statute [2] began to run on the date of injury. DeBoer, 673 P.2d at 913. Injury has been defined by the Arizona court as the damaging effect sustained by the plaintiff-patient. Id. at 914. The patient in DeBoer was being treated for various skin problems, and in August 1976, the patient's doctor diagnosed a lesion on the patient's back as a common wart. From that date until April of 1980, the patient noticed no change in the lesion. However, as evidence later showed, the lesion began to grow internally sometime in 1979, and in April 1980, the lesion was diagnosed as a malignant melanoma. The patient's chances of survival dropped from ninety-five percent in 1976 to only fifty to seventy-five percent in 1980. The patient filed suit in 1981 against the doctor who had missed the cancer (which was determined later to have existed at the time of his 1976 exam). The doctor raised a statute-of-limitations defense, claiming the suit was barred. Id. The Arizona court rejected the doctor's statute-of-limitations defense, stating: Where a medical malpractice claim is based on a misdiagnosis or a failure to diagnose a condition, the injury is not the mere undetected existence of the medical problem at the time the physician misdiagnosed or failed to diagnose it. Nor is the injury the mere continuance of the same problem in substantially the same state or the leaving of the patient at risk of developing a more serious condition. Rather, the injury is the development of the problem into a more serious condition which poses greater danger to the patient or which requires more extensive treatment. Id. (emphasis added) (citing Augustine v. United States, 704 F.2d 1074, 1078 (9th Cir.1983)). Based on its analysis of cases from other jurisdictions, the Arizona court concluded the patient was damaged and his `injury' occurred when the misdiagnosed lesion began to grow and threaten his life expectancy, not when the misdiagnosis occurred. Id. at 915. These principles are well supported by cases from other jurisdictions. For example, in a case similar to Murtha's, a Maryland court said, as to the defendant's negligent failure to diagnose cancer: In our view, a negligent misdiagnosis is not necessarily an injury for purposes of limitations; a wrongful act or omission is not the same as an injury. Indeed, the two need not necessarily occur simultaneously. Edmonds v. Cytology Servs. of Md., Inc., 111 Md.App. 233, 681 A.2d 546, 558 (Md. App.1996), aff'd sub nom Rivera v. Edmonds, 347 Md. 208, 699 A.2d 1194 (1997). The rule of law in other jurisdictions is that, under statutes requiring identification of the injury rather than the negligent act or omission, an injury in a negligent misdiagnosis case requires more than a continuing undiagnosed condition. See, e.g., Augustine, 704 F.2d at 1078 (injury was not the existing lump, but the development of it into cancer); Doe v. Cutter Biological, 844 F.Supp. 602, 608 (D.Idaho 1994) (applying Idaho law and holding that Doe's injury was not objectively ascertainable until he tested positive for HIV); Larcher v. Wanless, 18 Cal.3d 646, 135 Cal.Rptr. 75, 557 P.2d 507, 512 n. 1 (1976) (injury is damaging effect); Steingart v. Oliver, 198 Cal.App.3d 406, 243 Cal.Rptr. 678, 682 (1988) (undiagnosed breast cancer not injury until the plaintiff suffered . . . damaging effect or appreciable harm); Rivera, 699 A.2d at 1202 (suggesting that condition became injury when additional adverse consequences occurred); St. George, 484 S.E.2d at 891 (This is a misdiagnosis case, not a malpractice action based on negligently performed surgery. In every misdiagnosis case, the patient has some type of medical problem at the time the physician is consulted. But the injury upon which the cause of action is based is not the original detrimental condition; it is the injury which later occurs because of the misdiagnosis and failure to treat. (Citation omitted.)); Lo v. Burke, 249 Va. 311, 455 S.E.2d 9, 12 (1995) (plaintiff's condition, initially diagnosed as a cyst, became cancerous; the court held the plaintiff suffered a physical hurt [or injury] only when the cancer developed, relying on Locke v. Johns-Manville Corp., 221 Va. 951, 275 S.E.2d 900, 904 (1981), which held an injury is a positive, physical or mental hurt to the claimant, not legal wrong to him in the broad sense that his legally protected interests have been invaded); Paul v. Skemp, 242 Wis.2d 507, 625 N.W.2d 860, 873 (Wis.2001) (recurring headaches, misdiagnosed by the defendant, became injury when patient's arteriovenous malfunction either ruptured or could no longer be treated). Our definition of injury as physical or mental harm is consistent with the holdings in these cases when the claim is one of negligent misdiagnosis.