Court Opinion

ID: 9746317
Source: CourtListenerOpinion
Date Created: 2023-08-27 14:11:51.488466+00
Date Added: 2024-06-11T07:25:12.009528
License: Public Domain

NIGRO, Justice,
dissenting.
I respectfully disagree with the Majority Opinion. For the following reasons I believe that medical literature is required before a two schools of thought jury instruction may be given, that Appellees did not meet the threshold to warrant a two schools instruction, and that the Superior Court should be reversed and the case remanded for a new trial.
The two schools of thought doctrine was created as a defense in medical malpractice cases in order to allow each legitimate medical approach to be judged on its own merits and not solely by the rules and principles of a different, albeit authoritative, way of thinking. Under this doctrine, a physician will not be held liable for exercising his judgment in choosing a course of treatment supported by reputable and respected medical experts even if other medical experts would favor a different course of treatment. Trent v. Trotman, 352 Pa.Super. 490, 496-97, 508 A.2d 580, 584 (1986). In essence, the two schools of thought doctrine is an effort not to inhibit the legitimate practice of alternative or “minority” treatment by medical practitioners.
The doctrine is rooted in the principle that juries, with their limited medical knowledge, should not be forced to decide which of two acceptable treatments a defendant physician should have performed. At issue here is what type of evidence will validate a second school of thought defense before *481the trial judge may instruct the jury on the two schools of thought doctrine.
When two schools is asserted as a defense, the burden is on the defendant physician to prove that there are two schools of thought. Jones v. Chidester, 531 Pa. 31, 610 A.2d 964 (1992). In determining whether the instruction should be given, the trial court must initially evaluate whether the defendant has produced adequate factual support for his claim that competent medical authority is divided. See Tesauro v. Perrige, 437 Pa.Super. 620, 626, 650 A.2d 1079, 1082 (1994), appeal denied, 541 Pa. 627, 661 A.2d 874 (1995). I believe we should further refine Jones and require that, in order to establish adequate factual support that competent medical authority is divided, a defendant must provide medical teachings in the form of literature.
Such a requirement would recognize that a school of thought as it is used in the two schools doctrine is more than a spontaneous agreement among an ad hoc group of colleagues. Rather, it is by definition a more formal mode of practice, system or discipline with its own theoretical basis, medical principles and protocol. See 61 Am. JuR.2d: Physicians, Surgeons & Other Healers § 214 (1981) (“the school must be a recognized school of good standing, which has established rules and principles of practice for the guidance of all its members, as respects diagnosis and remedies, which each member is supposed to observe in any given case”).
Further, in order to be a “school,” the approach, technique, treatment or procedure must be communicated to others who adopt and follow those methods. The shared teachings only become a school when the followers are numerous and the protocol is established, understood, and embraced at least among the defined group of disciples. As such, a considerable number of reputable and respected practitioners has long been the requirement in Pennsylvania in order to constitute a school. See Brannan v. Lankenau Hospital, 490 Pa. 588, 417 A.2d 196 (1980); Duckworth v. Bennett, 320 Pa. 47, 181 A. 558 (1935); Remley v. Plummer, 79 Pa.Super. 117, 121 (1922). The unadopted beliefs, writings and teachings of one individu*482al provide inadequate factual support for a school of thought. See Tesauro, 437 Pa.Super. at 627, 650 A.2d at 1083.1
The two schools of thought doctrine is a complete defense where “competent medical authority is divided.” See Jones, 531 Pa. 31, 610 A.2d 964; see also Furey v. Thomas Jefferson Univ. Hosp., 325 Pa.Super. 212, 226, 472 A.2d 1083, 1090-91 (1984). That determination can not be a casual exercise and must be based, at a minimum, on a proof that tenets and standards of the school have been “taught,” (i.e., communicated) to its members before a jury is permitted to consider the defense. Thus, I believe professional literature descriptive of and in support of the defendant’s course of treatment must be admitted into evidence in order for the trial court to determine as a matter of law that “competent medical authority is divided.”2 If the trial court so finds, a second school jury instruction must be given. It is then for the jury as fact finder to determine whether the physician, in the exercise of *483his or her judgment, followed a course of treatment advocated by a considerable number of recognized and respected professionals in his or her area of expertise. See Differing Schools of Thought Doctrine, S.J.I. 10.04 (Civ.).
In the instant matter, both Appellees O’Connor and Hamilton admitted at trial that neither had ever performed resection of a vagal tumor prior to Appellant’s procedure. It thus goes without saying that neither had ever attempted such surgery under local anesthetic. Dr. Hamilton’s expert witness was Eugene Myers, M.D., a board certified otolaryngologist with a subspecialty in head and neck surgery. Myers testified that in 1988 when Appellant’s tumor was excised, a considerable number of reputable, respected physicians throughout the United States and the world used local anesthetic for the removal of tumors in the neck. However, the only examples he could offer were the practices of one colleague, a medical missionary physician-surgeon who operated in India where hospital facilities were scarce. He further testified that he himself used local anesthetic in such procedures. Dr. O’Con-nor’s expert witness, William M. Keane, M.D., a board certified otolaryngologist with a subspecialty in head and neck tumor surgery, similarly testified that, while he never performed such surgery under local anesthetic himself, it was his opinion that the use of local anesthetic for procedures that deeply invade the neck is “appropriate.” The Majority Opinion quotes this portion of his testimony, overlooking that he specifically declined to testify that it was an “accepted practice” to use local anesthetic under the circumstances. Thus, neither expert presented evidence that such was the practice of a “considerable number” of surgeons in this or any other first world country. Neither expert was aware of nor cited to any medical literature advocating the use of local anesthetic in this type of operation.
The record reflects that Appellees offered no evidence of medical literature, available at the time and consulted by them, supporting that competent medical authority is divided on the use of general or local anesthetic in the surgery performed on the Appellant. Thus, without such medical *484literature, Appellees failed to establish that there was a school of thought whose selection by them would constitute a defense to their deviation from the medical standards of the majority.3 Therefore, I believe the jury was improperly instructed on the two schools of thought doctrine. Such error is not harmless. In determining whether fundamentally erroneous instructions require the grant of a new trial, whether such instructions did or did not bring about the complained of verdict is not the question. If it appears that such instruction might have been responsible for the verdict, a new trial is mandatory. D’Angelis v. Zakuto, 383 Pa.Super. 65, 71, 556 A.2d 431, 434 (1989) (citing Riesberg v. Pittsburgh & Lake Erie R.R., 407 Pa. 434, 180 A.2d 575 (1962) (emphasis supplied)).
As it appears that the two schools instruction permitted the jury to improperly consider that a second school of thought advocating the use of local anesthetic existed, I would reverse the order of the Superior Court and remand to the Court of Common Pleas for a new trial in keeping with the requirement that medical literature be produced in support of a second school before a two schools instruction is given.

. The concurring opinion asserts that, in medicine, a "significant amount of valid information is passed along orally, such as on rounds or in conferences.” However, in teaching hospitals, while "rounds” may be led by "reputable and respected” doctors, the information is primarily communicated to interns or residents who have not yet achieved the status of "reputable and respected medical professionals” themselves. Thus, as held in Tesauro, the unadopted teachings of one doctor, though he/she him/herself may be highly regarded, does not constitute a "school” for legal purposes simply because he/she shares his/her views with his/her students. Furthermore, the protocol at medical conferences or symposia is that a "reputable and respected medical professional” is invited to deliver his/her paper to the convening group. Unless and until other reputable and respected colleagues adopt the advocated approach, it is only a theory and not a "school.” Nonetheless, should it become a school, its basis is always the paper prepared by the speaker through which his/her teachings are communicated. Thus, as in the law, a theory is merely a theory or an argument for a point of view until it is adopted, memorialized and disseminated for others to follow.

. Appellant would have the requisite literature be a "current recognized medical text, a current respected peer review article or the current recommendations of a national association.” I, however, would decline to further characterize the “literature.” Rather, I would simply require that this literature must be descriptive of the approach taken, must have been available to the defendant at the time of choosing the alternative treatment, the defendant must have had knowledge of such literature and have consulted such in making the choice of treatment.

. In fact, the testimony presented by the defense experts in this case fails to establish competent medical authority is divided under Jones. Therefore, it was error for the trial judge to give the "two schools” jury instruction.