Court Opinion

ID: 5515824
Source: CourtListenerOpinion
Date Created: 2022-01-10 15:11:21.789133+00
Date Added: 2024-06-11T08:34:19.347008
License: Public Domain

In the
          Court of Appeals
  Second Appellate District of Texas
           at Fort Worth
       ___________________________
            No. 02-21-00168-CV
       ___________________________

JOSE PIGNANO AND CORA PIGNANO, Appellants

                       V.

      ROBERT L. CASH, M.D., Appellee

     On Appeal from the 96th District Court
            Tarrant County, Texas
        Trial Court No. 096-298964-18

     Before Birdwell, Bassel, and Womack, JJ.
     Memorandum Opinion by Justice Bassel
                          MEMORANDUM OPINION

                                   I. Introduction

       In three issues, Appellants Jose Pignano and his wife, Cora Pignano, challenge

a summary judgment granted in favor of Appellee Robert L. Cash, M.D. on their

health care liability claim. Dr. Cash’s motion for summary judgment asserted that

Mr. Pignano’s1 claim was time barred by the two-year statute of limitations contained

in Texas Civil Practice and Remedies Code Section 74.251(a) that applies to health

care liability claims.

       Mr. Pignano alleged that Dr. Cash had failed to timely diagnose a mass in his

lungs as cancerous and that the delay in the diagnosis caused the cancer to

metastasize, which in turn required a more debilitating treatment and lessened his life

expectancy. Dr. Cash predicated his summary-judgment motion on the opinion of

Mr. Pignano’s expert that Dr. Cash departed from the standard of care on an

ascertainable date outside the limitations period. In addition to Mr. Pignano’s first

issue generally challenging the summary judgment, his second and third issues

contend that to grant summary judgment on this basis was error because Dr. Cash

provided a course of treatment that extended to a date that saved his claim from being

time barred or because the last ascertainable departure from the standard of care

occurred on a date that was within the limitations period.

       As Mr. Pignano was Dr. Cash’s patient, we will refer to Mr. Pignano
       1

individually throughout the opinion even when referring collectively to both
Appellants.

                                           2
      Mr. Pignano’s second issue faces a hurdle: if the date that a departure from the

standard of care can be ascertained, that date triggers the commencement of the

limitations time period. Should there be an ascertainable date, a plaintiff may not rely

on the period of the course of treatment as a means of extending the date of the

commencement of the statute of limitations. Applying the ascertainable date on

which Dr. Cash allegedly departed from the standard of care results in Mr. Pignano’s

claim being barred by limitations. His third issue fails because we conclude that his

expert did not render the opinion that departures from the standard of care occurred

within the limitations period.     Accordingly, we affirm the trial court’s summary

judgment.

                    II. Factual and procedural background

      A.     The chronology of relevant events that applies to the question of
             whether Mr. Pignano’s claims are barred by limitations

      Mr. Pignano was referred by his primary-care physician to Dr. Cash, a

pulmonologist, for evaluation when a CT scan revealed a mass in Mr. Pignano’s lung

that was described as “suspicious for malignancy.” That referral set in motion a

chronology of events that are pivotal to the question of whether Mr. Pignano’s claim

against Dr. Cash is time barred:

             May 19, 2014: Mr. Pignano has his initial visit with Dr. Cash after

             Mr. Pignano was “referred for evaluation of [a] right apical lung mass.”

             A “patient visit note” contains Dr. Cash’s assessment and provides for

                                           3
      “watchful waiting” and for another CT scan of Mr. Pignano’s chest in

      August 2014 as follows:

      Pulmonary infiltrate; he has no constitutional symptoms to speak
      of. No productive cough is currently reported. He [has] not had
      weight loss or further adenopathy. At this point[,] the best
      approach will be watchful waiting with a repeat CT scan of his
      chest in August. This will be three months from his previous
      film. He has an insignificant and distant smoking history. If he
      has further problems[,] including hemoptysis, chest pain, dyspnea,
      weight loss, fever, night sweats, or adenopathy, he should give us
      an immediate call. If the CT scan shows [that] the problem has
      resolved[,] [then] he will not need further follow-up. If the
      problem gets worse[,] th[e]n we can decide appropriate measures,
      including biopsies.

September 9, 2014: Dr. Cash examines Mr. Pignano and postpones the CT

scan, which was supposed to be completed in August per the notes from the

first visit, with the following note: “Pulmonary infiltrate; as noted before he

has no constitutional symptoms. This most likely means a benign process[,]

but a CT scan in November will give us a full six months of follow-up. If he

has problems, he’s to give us a call immediately.”

November 11, 2014: A second CT is performed on Mr. Pignano’s chest. The

CT scan reveals that the mass in Mr. Pignano’s chest “is not significantly

increased in size.” Though Dr. Cash did not physically examine Mr. Pignano

after the second scan, the scan results were sent to Dr. Cash. After review of

the scan, Dr. Cash replied that Mr. Pignano is “stable at present[;] repeat CT 12

months unless he has symptoms.”

                                    4
December 15, 2015: Dr. Cash orders another CT scan of Mr. Pignano’s chest.

February 18, 2016: A third CT scan of Mr. Pignano’s chest reveals that the

mass identified in the prior CT scans is slightly increased in size.

February 22, 2016: Dr. Cash sees Mr. Pignano. The “patient visit note” states

that a needle biopsy should be performed:

       Lung mass; this mass has gotten slightly larger. We will need to
       arrange for a percutaneous needle biopsy wherever his insurance
       will allow. He does not need to be off work long. If the mass is
       benign[,] we will not do anything further. If the mass is
       cancerous[,] then we may try for either resection or radiation.

April 14, 2016: Dr. Cash orders a “Chest CT-Guided Needle Biopsy.”

April 26, 2016:     The results of the needle biopsy show that the mass is

cancerous. Dr. Cash notifies Mr. Pignano that the mass should be removed.

Summer 2016: Mr. Pignano undergoes treatment, including surgical removal

of the mass, chemotherapy, and radiation.

September 6, 2016: Counsel for Mr. Pignano provides notice to Dr. Cash in

accordance with Section 74.051 et seq. of the Texas Civil Practice and

Remedies Code. The notice states, “In particular, my client’s complaint with

you concerns your failure to timely and appropriately diagnose his lung cancer.

The failure to provide Mr. Pignano with medical treatment [that] met the

standard of care resulted in treatment[,] which has increased his medical

expenses and lowered his life expectancy.”

                                      5
      April 9, 2018: Mr. Pignano sues Dr. Cash for negligence. Mr. Pignano’s

      original and amended petition in the section titled “Actions of Defendant”

      focused on the failure of Dr. Cash to initially diagnose that Mr. Pignano was

      suffering from cancer:

             Despite possessing and having within his knowledge and control
             evidence of [Mr. Pignano’s] cancerous tumor, [Dr. Cash] collected
             blood samples from [Mr.] Pignano and had such samples
             inspected for a myriad of indications, such finding being
             indicative of serious, worsening, and possibly a lethal existing
             disease if left untreated. [Dr. Cash] failed to correctly interpret
             the CT Scan he reviewed and then ordered, and failed to
             communicate to [Mr.] Pignano the serious and worrisome
             findings highlighted by a radiologist, failed to refer [Mr.] Pignano
             to undergo a needle biopsy and further evaluation and treatment,
             and instead did nothing for over one year despite indications that
             [Mr.] Pignano was likely suffering from a pulmonary malignancy.
             If [Dr. Cash] had correctly recognized the significance of an apical
             pulmonary mass in a sixty-four[-]year[-]old man, informed him of
             the finding and the significance of such finding, acted upon and
             thereafter properly referred him for biopsy, further evaluation,
             and treatment for likely lung cancer, diagnosis, treatment, and
             therapy could have been instituted and initiated in months prior
             to April[] 2016. Instead, due to [Dr. Cash’s] failure to recognize
             or appreciate the significance of the CT Scan finding, and his
             resulting failures to communicate to [Mr.] Pignano the need for
             immediate follow-up by biopsy, there was a delay of
             approximately sixteen months until [Mr.] Pignano followed-up
             with a biopsy. after which [Mr.] Pignano underwent surgery,
             followed by radiation and chemotherapy.2

      2
       Mr. Pignano’s petitions generally alleged the consequences of the disease
process’s continuing after Dr. Cash’s failure to diagnose but did not allege these as
departures from the standard of care:

                                          6
      Both petitions allege the following omissions by Dr. Cash:

            1. In failing to correctly interpret multiple CT Scans of
            [Mr. Pignano’s] chest;

                  2. In failing to recognize the significance of the continuing
            presence of an apical pulmonary mass;

                  3. In failing to immediately refer [Mr.] Pignano to undergo
            a biopsy; [and]

                  4. In failing to advise or inform [Mr.] Pignano of the
            continued presence of an apical pulmonary mass as reported to
            him.

      B.    The limitations ground of Dr. Cash’s traditional motion for
            summary judgment, the evidence Dr. Cash offered to support that
            ground, and Mr. Pignano’s counter evidence

      Dr. Cash filed both a traditional and a no-evidence motion for summary

judgment. Dr. Cash moved for traditional summary judgment on the ground that Mr.

Pignano’s claim was time barred:

      Under the traditional summary[-]judgment standard, the evidence proves
      that the alleged negligence occurred—according to the Pignanos and
      their own expert—in November 2014. The Pignanos did not file suit
      until April 2018, well over three years after the alleged negligence. With
      a strict two-year limitations period governing their claims, the Pignanos’

      However, if Defendant Dr. Cash had recommended and referred
      [Mr. Pignano] for the needle biopsy in December[] 2014, or at some time
      during the year 2015, or earlier in 2016, in reasonable medical probability
      and likelihood, the then[-]existing tumor would not have extended past
      its margins, nor would it have metastasized to lymph nodes; if the tumor
      had been so detected earlier, [Mr. Pignano] would have had a diagnosis
      of a much lesser stage of tumor, thereby greatly increasing his life
      expectancy, his survival outlook, and eliminating the medical necessity of
      the intensive, debilitating, and hazardous chemotherapy he had to
      undergo.

                                          7
       claims are barred by the statute of limitations. Dr. Cash is entitled to
       summary judgment because the statute of limitations expired before the
       Pignanos filed suit.

       Mr. Pignano’s retained expert that the quote references was Dr. Avi Markowitz,

an oncologist. Excerpts from Dr. Markowitz’s deposition are relied on by both

parties.

       Dr. Cash’s summary-judgment excerpts from Dr. Markowitz’s deposition—as

did the allegations in Mr. Pignano’s petitions—served to localize the date of

Dr. Cash’s departure from the standard of care to a particular instance by emphasizing

Dr. Markowitz’s opinion that Dr. Cash’s departure from the standard of care occurred

in November 2014. The framework of Dr. Markowitz’s criticisms of Dr. Cash is set

out in the following exchange with Dr. Cash’s counsel:

       [Dr. Cash’s counsel]: Dr. Markowitz, you think [a biopsy] definitely
       should have been done in March of 2014, but certainly no later than
       November of 2013 [(sic)]?

              [Dr. Markowitz]: Right. We would have done it in March, but
       giving a few months follow-up and then doing it at that point, I would
       not have gone after that. I would give him that much leeway.

             [Dr. Cash’s counsel]: But the criticism is not of the 2016 care, the
       two times in 2014 where he didn’t do the biopsy?

             [Dr. Markowitz]: Correct. Once he realized this was cancer[,] he
       went ahead and got the biopsy done. That’s what you do. And we
       would have done it, like I said, a little differently, but that’s [the] art of
       medicine. That I don’t go after people for.

                                             8
With respect to Dr. Markowitz’s assessment of Dr. Cash’s treatment before

November 2014, Dr. Markowitz also stated that Dr. Cash’s decision to delay the CT

scan for three months was not one he liked, but he could live with it.

      In later questioning, Dr. Markowitz amplified on why a departure from the

standard of care occurred in November 2014 because Dr. Cash failed to do what was

needed to obtain a diagnosis:

      [Dr. Cash’s counsel]: Can I -- just based on what you just said and this
      answer and the previous answer. I want to make sure. So in the May of
      2014 timeframe, while in [your] institution you would have biopsied and
      investigated it further, it was not necessarily negligent for Dr. Cash not
      to do something further. It is really in November when he didn’t do
      something further that he [fell] below the standard of care.

             [Dr. Markowitz]: Correct.

            [Dr. Cash’s counsel]: And then when [Dr. Cash] deals with [Mr.
      Pignano] again, he met the standard of care, so all we are really talking
      about is when he breached the standard of care was November of 2014.

            [Dr. Markowitz]: Yes. At that point I say, now it is not
      something you can monitor . . . anymore. Now you need to get a
      diagnosis.

      In his summary-judgment response, Mr. Pignano cites other portions of

Dr. Markowitz’s deposition to rebut Dr. Cash’s portrayal that the only departure from

the standard of care occurred in November 2014. In essence, these opinions are that

a proper diagnosis indicated that Mr. Pignano was already suffering from lung cancer

in the May 2014 to November 2014 time period. But even in the excerpt quoted by

                                           9
Mr. Pignano, Dr. Markowitz reiterated that he gave Dr. Cash leeway by noting that he

“would have given him three months to do a follow-up.”

      The response then shifts to the 2016 time frame to argue that Dr. Markowitz

opined that there were departures from the standard of care once Dr. Cash had the

results of the third CT scan showing that the mass had grown and that a needle

biopsy should be performed. The response quotes Dr. Markowitz’s testimony and

offers Mr. Pignano’s interpretations of what conclusions should have been drawn

from that testimony:

      Although Dr. Markowitz agreed that [Dr. Cash’s] referral of
      [Mr. Pignano] for a biopsy was appropriate in the February 22, 2016
      visit, he further testified that his treatment would have been different in
      that:

            A.     It fits, although I will tell you we would do that
            differently. We would have gotten a PET/CT as the next
            step because one of the critical issues is are the hilar
            mediastinal lymph nodes involved[,] and if it lit up on CT,
            we would have recommended a bronchoscopy with biopsy
            to sample the nodes at that time rather than doing a
            percutaneous biopsy likely. But that is small. I mean, I
            would have done that differently[;] he did get a biopsy and
            that was appropriate.

                 [Dr. Cash’s counsel]: When you said lights up on
            CT you meant what?

                    [Dr. Markowitz’s]: Oh, it’s a [lymphatic], excuse me.
            If the nodes light up on PET[,] that is much more
            significant because now you are probably looking at least a
            stage three disease.

            In other words, a PET/CT would have provided earlier indication
      of lymph node involvement, and hence, stage three disease.

                                          10
            Although the referral for a biopsy, finally, was appropriate,
      Dr. Markowitz further commented on the continuing violation of the
      standard of care after the third CT scan when he testified:

             A. Like I said, my biggest concern right here is what
             happened between February 22nd and April 26th, that is a
             two-month gap. We would do that[,] and I don’t recall
             what the issue was for getting the biopsy, why it took two
             months.

             Of particular importance to the events and timeline of this case[]
      is Dr. Markowitz’s testimony regarding what injury or damage
      Mr. Pignano suffered during the two-month delay between the ordering
      of the biopsy and the results. He testified as follows:

             [Dr. Cash’s counsel]: To follow back up on that, she
             phrased it as damage, what damage occurred, but what
             harm actually occurred to Mr. Pignano by the two-month
             delay?

                    [Dr. Markowitz’s]: You don’t know. I mean, the
             likelihood that it changed and [that] suddenly he had
             metastasis, it is a low likelihood, but I have much more of a
             sense of urgency once you know, okay, this is going to be
             cancer, we need to find out exactly what kind it is and we
             need to complete a staging because if he is still candidate
             for curative intense surgery[,] we need to get there.
             [Record references omitted.]

      After this portrayal of the departures from the standards of care by Dr. Cash,

the response crystalizes its view of how Dr. Cash’s errors harmed Mr. Pignano:

      Essentially, the question in this lawsuit is whether Dr. Cash’s delay in
      making an appropriate diagnosis caused the cancer in Mr. Pignano’s lung
      to metastasize into the lymph nodes so as to make necessary in addition
      to surgery, which would have been necessary in any case, the further
      treatments of chemotherapy and radiation, and due to a higher stage,
      cause him to suffer a higher chance of cancer recurrence and a lowered
      life expectancy.

                                          11
      The remainder of the response catalogs Dr. Markowitz’s testimony regarding

how the cancer mutated during the post-2014 delay in treatment and moved to a

higher stage of severity. This pathology caused the cancer not to be localized but to

spread into other regions of Mr. Pignano’s body, such as his lymph nodes. The

response concedes that Dr. Markowitz could not pinpoint when this occurred but

could only opine that it was between November 2014 and February 2016.

      With this mix of evidence before it, the trial court granted summary judgment

and ordered that Mr. Pignano take nothing. Mr. Pignano appealed.

                                  III. Analysis

      A.     Standard of review

      In a summary-judgment case, the issue on appeal is whether the movant met

the summary-judgment burden by establishing that no genuine issue of material fact

exists and that the movant is entitled to judgment as a matter of law. Tex. R. Civ. P.

166a(c); Mann Frankfort Stein & Lipp Advisors, Inc. v. Fielding, 289 S.W.3d 844, 848 (Tex.

2009). We review a summary judgment de novo. Travelers Ins. v. Joachim, 315 S.W.3d

860, 862 (Tex. 2010).

      With a traditional motion for summary judgment, “[a] court must grant a

‘traditional’ motion for summary judgment ‘forthwith if [the summary-judgment

evidence] show[s] that . . . there is no genuine issue as to any material fact and the

moving party is entitled to judgment as a matter of law on the issues expressly set

                                           12
out.’” Draughon v. Johnson, 631 S.W.3d 81, 87 (Tex. 2021) (citing Tex. R. Civ. P.

166a(c)).

      We take as true all evidence favorable to the nonmovant, and we indulge every

reasonable inference and resolve any doubts in the nonmovant’s favor. 20801, Inc. v.

Parker, 249 S.W.3d 392, 399 (Tex. 2008); Provident Life & Accident Ins. v. Knott, 128

S.W.3d 211, 215 (Tex. 2003). We also consider the evidence presented in the light

most favorable to the nonmovant, crediting evidence favorable to the nonmovant if

reasonable jurors could and disregarding evidence contrary to the nonmovant unless

reasonable jurors could not. Mann Frankfort, 289 S.W.3d at 848. We must consider

whether reasonable and fair-minded jurors could differ in their conclusions in light of

all the evidence presented. See Wal-Mart Stores, Inc. v. Spates, 186 S.W.3d 566, 568 (Tex.

2006); City of Keller v. Wilson, 168 S.W.3d 802, 822–24 (Tex. 2005).

      A defendant is entitled to summary judgment on an affirmative defense if the

defendant conclusively proves all the elements of that defense. Chau v. Riddle, 254 S.W.3d

453, 455 (Tex. 2008); see Tex. R. Civ. P. 166a(b), (c). To accomplish this, the defendant

must present summary-judgment evidence establishing each element of the affirmative

defense as a matter of law. Chau, 254 S.W.3d at 455; Ryland Grp., Inc. v. Hood, 924 S.W.2d

120, 121 (Tex. 1996).

                                           13
       B.     The statutory provision establishing the statute of limitations on
              health care liability claims; the precedents interpreting the
              provision to hold that if there is an ascertainable date when the
              departures from a standard of care occurred, limitations run from
              that date; and the precedents applying the ascertainable-date
              principle to a failure to diagnose cancer

       Section 74.251 of the Texas Civil Practice and Remedies Code establishes the

statute of limitations for health care liability claims as follows:

       Notwithstanding any other law and subject to Subsection (b), no health
       care liability claim may be commenced unless the action is filed within
       two years from the occurrence of the breach or tort or from the date the
       medical or health care treatment that is the subject of the claim or the
       hospitalization for which the claim is made is completed[.]

Tex. Civ. Prac. & Rem. Code Ann. § 74.251(a). 3 Though Section 74.251(a) provides

three alternative dates for the commencement of the statute of limitations, the Texas

Supreme Court has made the following principles clear:

       •      “A plaintiff may not choose the most favorable date that falls within [the]

              three categories.”     Shah v. Moss, 67 S.W.3d 836, 841 (Tex. 2001)

              (emphasis added).

       3
        A “health care liability claim” is defined as

       a cause of action against a health care provider or physician for
       treatment, lack of treatment, or other claimed departure from accepted
       standards of medical care, or health care, or safety or professional or
       administrative services directly related to health care, which proximately
       results in injury to or death of a claimant, whether the claimant’s claim or
       cause of action sounds in tort or contract.

Tex. Civ. Prac. & Rem. Code Ann. § 74.001(13).

                                             14
      •      “[I]f the date the alleged tort occurred is ascertainable, limitations must

             begin on that date.” Id.

      •      “And if the date is ascertainable, further inquiry into the second and

             third categories is unnecessary. Id. 4

Section 74.251(a) contains no discovery rule: the statute of limitations begins to run

from the dates of the events specified in the statute, irrespective of the claimant’s

delayed knowledge that a departure from the standard of care has occurred.5 See

Walters, 307 S.W.3d at 298 n.28.

      4
        Shah analyzed a prior statute establishing the statute of limitations for health
care liability claims. 67 S.W.3d at 841 (analyzing former Tex. Rev. Civ. Stat. Ann.
art. 4590i, § 10.01). That statute provided the same alternatives for accrual that
Section 74.251(a) provides, specifically that

      no health care liability claim may be commenced unless the action is filed
      within two years from the occurrence of the breach or tort or from the
      date the medical or health care treatment that is the subject of the claim
      or the hospitalization for which the claim is made is completed[.]

Act of April 19, 1977, 65th Leg., R.S., ch. 817, § 10.01, 1977 Tex. Gen. Laws 2039,
2052 (Medical Liability and Insurance Improvement Act of Texas, since amended),
repealed by Act of May 16, 2003, 78th Leg., R.S., ch. 204, § 10.09, 2003 Tex. Gen. Laws
847, 884.
      5
       As the Texas Supreme Court explained,

      It is undeniable that the statute of limitations contains no discovery rule.
      We fashioned such a rule in a 1967 sponge case to suspend an earlier
      limitations provision. Gaddis v. Smith, 417 S.W.2d 577, 580 (Tex. 1967).
      The [l]egislature in 1975 abrogated the court-fashioned discovery rule.
      See Sax v. Votteler, 648 S.W.2d 661, 663 n.1 (Tex. 1983) (discussing the
      Professional Liability Insurance for Physicians, Podiatrists, and Hospitals
      Act of 1975, 64th Leg., R.S., ch. 330, § 1, 1975 Tex. Gen. Laws 864, 865,

                                           15
       The supreme court in Shah recognized that if a patient is subject to a course of

treatment, there may not be an exact date of accrual, but that is the exception rather

than the rule:

       However, there may be instances when the exact date the alleged tort
       occurred cannot be ascertained. The second category in [S]ection 10.01
       contemplates such a situation “wherein the patient’s injury occurs during
       a course of treatment for a particular condition and the only readily
       ascertainable date is the last day of treatment.” But before the last treatment
       date becomes relevant to determining when limitations begins, the plaintiff must
       establish a course of treatment for the alleged injury. Moreover, if the defendant
       committed the alleged tort on an ascertainable date, whether the plaintiff established a
       course of treatment is immaterial because limitations begins to run on the ascertainable
       date.

67 S.W.3d at 841 (emphasis added) (citations omitted).

       The Fourteenth Court of Appeals applied the principles from Shah to facts

analogous to the ones before us. See Estate of Klovenski v. Kapoor, No. 14-13-00850-CV,

2015 WL 732651, at *5 (Tex. App.—Houston [14th Dist.] Feb. 19, 2015, no pet.)

(mem. op. on reh’g). Kapoor involved a patient who had five office visits with a

physician. Id. at *4. During the first four visits, the physician failed to diagnose a

      which removed the “accrual” language that had led the Court to find a
      discovery rule embedded within the statute). Accordingly, in a 1985
      case, this Court acknowledged that the [l]egislature had abrogated the
      discovery rule. Morrison v. Chan, 699 S.W.2d 205, 208 [(Tex. 1985)] (“[In
      Gaddis, we] held that a cause of action does not accrue until the plaintiff
      knows, or has reason to know, of his injury. In contrast, [A]rticle 5.82,
      [S]ection 4 contains no accrual language and thus imposes an absolute
      two-year statute of limitations regardless of when the injury was
      discovered.” . . . (emphasis omitted) (quoting Nelson v. Krusen, 678
      S.W.2d 918, 920 (Tex. 1984))[)].

Walters v. Cleveland Reg’l Med. Ctr., 307 S.W.3d 292, 298 n.28 (Tex. 2010).

                                                 16
lump in the patient’s leg as cancerous. Id. On the fifth visit, the physician properly

diagnosed the lump as cancerous. Id. The date of the last visit was pivotal to the

viability of the patient’s claim because the claim was time barred if limitations was not

measured from the date of the fifth visit. Id.

       Kapoor held that the breach of the standard of care by the physician was

ascertainable, and thus, limitations was measured from the date of the last occurrence

of a departure from the standard of care. Id. at *5–6. The court summarized its

conclusion and cataloged the cases supporting that conclusion as follows:

       We determine that the dates of [the physician’s] alleged breaches are
       ascertainable; therefore, we measure limitations from the occurrences of
       the alleged breaches. See Shah, 67 S.W.3d at 841. The failure to diagnose
       or treat a medical condition does not establish a course of treatment. See
       Bala v. Maxwell, 909 S.W.2d 889, 892 (Tex. 1995); Rowntree v. Hunsucker,
       833 S.W.2d 103, 105–06 (Tex. 1992) . . . (“While the failure to treat a
       condition may well be negligent, we cannot accept the self-contradictory
       proposition that the failure to establish a course of treatment is a course
       of treatment.”). [The physician’s] alleged negligence for failure to
       diagnose, treat, and advise [the patient] of her cancer could have
       occurred only on the days [the physician] examined [the patient]; those
       days are readily ascertainable. See Shah, 67 S.W.3d at 844 (doctor’s failure
       to provide follow-up treatment could have occurred only on check-up
       visits when doctor had an opportunity to order follow-up treatment);
       Husain v. Khatib, 964 S.W.2d 918, 919–20 (Tex. 1998) (doctor’s failure to
       take action to diagnose and treat cancer could have occurred only during
       office visits); Bala, 909 S.W.2d at 892 (same).

Id. at *5.

       With its premise in place—that the dates of the acts of malpractice were

ascertainable—Kapoor held that limitations began to run on each visit at which the

physician failed to properly diagnose the lump as cancerous. Id. Because limitations

                                           17
could not be measured from the date when the physician properly diagnosed the

presence of cancer, the patient could not use the date of her fifth visit as an

occurrence triggering the commencement of limitations to save her claims from being

barred by limitations. Id. Specifically, the court held, “Therefore, [the physician] was

not negligent under appellants’ alleged standard of care for failure to diagnose, treat,

and advise [the patient] of her cancer on [the date of the fifth visit]. We do not

measure limitations from this date.” Id.

      Our court has also discussed how the failure to diagnose cancer is a tort that

occurs on an ascertainable date—the date that the failure to diagnose occurred—and

does not involve a course of treatment that extends limitations until the cancer is

properly diagnosed. See Gilbert v. Bartel, 144 S.W.3d 136, 143 (Tex. App.—Fort Worth

2004, pet. denied). We detailed why a failure to diagnose does not create a course of

treatment as follows:

      Because, as we hold above, the date the alleged tort or breach took place
      is ascertainable, a course[-]of[-]treatment analysis is immaterial to
      determining when limitations began to run. It is also unimportant to our
      inquiry whether the tort is characterized as a failure to diagnose cancer
      or as an improper course of treatment based on a misdiagnosis. The
      [appellants’] complaint is that [the physician] was negligent in not taking
      actions—testing, referrals to specialists, proper examinations—that
      would have led to earlier discovery of [the patient’s] cancer. Those
      events, or nonevents, occurred on specific ascertainable dates. The
      Texas Supreme Court has held that when a physician fails to diagnose a
      condition, the continuing nature of the diagnosis does not extend the
      tort for limitations purposes. “‘While the failure to treat a condition may
      well be negligent, we cannot accept the self-contradictory proposition
      that the failure to establish a course of treatment is a course of
      treatment.’” Furthermore, neither the mere continuing relation between

                                           18
      physician and patient nor the continuing nature of a diagnosis is
      sufficient to create a course of treatment.

Id. (footnotes omitted).

      Thus, a failure to diagnose cancer is episodic for the purpose of limitations: the

visit at which the failure to diagnose occurs is the ascertainable date when the

departure from the standard of care occurs. The fact that later examinations produce

a proper diagnosis does not create a course of treatment that triggers the

commencement of limitations at the cancer’s eventual discovery.6

      C.     Why we conclude that Dr. Cash’s alleged departures from the
             standard of care occurred on an ascertainable date and that the
             application of that date establishes that Mr. Pignano’s claim is
             barred by limitations

      The question before us is how many discrete, ascertainable departures from the

standard of care occurred. Whether there was a datable ascertainable breach or

departure impacts Mr. Pignano’s argument in his second issue that limitations was

triggered only at the end of his course of treatment. Should we reject his course-of-

treatment argument, Mr. Pignano’s fallback in his third issue is that Dr. Markowitz

opined that there was a breach of the standard of care that occurred in 2016 and that

measuring limitations from that date makes his claim timely.           We reject both

arguments.

      6
        Because Mr. Pignano gave notice of his claim, the statute of limitations was
tolled for seventy-five days. See Tex. Civ. Prac. & Rem. Code Ann. § 74.051(c).
Because we hold that the ascertainable date that limitations commenced was in
November 2014, the seventy-five-day tolling provision has no effect on the outcome
of this appeal.

                                          19
      There is no question that Dr. Markowitz opined that Dr. Cash had failed to

properly diagnose and treat Mr. Pignano in November 2014. But Mr. Pignano tries to

shift the analysis from an ascertainable date to a course of treatment by arguing that

Dr. Cash’s description of his approach as “watchful waiting” establishes that there

was a course of treatment that flows into the eventual diagnosis of his cancer and not

a specific episode of malpractice. But semantics does not alter the reality that the

term watchful waiting means that Dr. Cash decided to wait from an ascertainable date

to take the action that Dr. Markowitz opines that he should have taken—biopsying

the mass to obtain what Dr. Markowitz said was required (i.e., the “need to get a

diagnosis”). The case law is clear that when such an ascertainable date exists, a

plaintiff cannot rely on the theory that there was a course of treatment.

      Mr. Pignano also emphasizes that his disease was apparently metastasizing and

becoming more severe in the time period between the 2014 failure to diagnose and

Dr. Cash’s ordering a needle biopsy in February 2016. This argument cannot wire

around the supreme court’s statement that “if the defendant committed the alleged

tort on an ascertainable date, whether the plaintiff established a course of treatment is

immaterial because limitations begins to run on the ascertainable date.” See Shah, 67

S.W.3d at 841. The argument also cannot evade the principle that “[w]hile the failure

to treat a condition may well be negligent, we cannot accept the self-contradictory

proposition that the failure to establish a course of treatment is a course of

treatment.” Rowntree, 833 S.W.2d at 105–06. It is also contrary to the holdings of the

                                           20
Fourteenth Court of Appeals and of our court that we have detailed above. See

Kapoor, 2015 WL 732651, at *5 (“We determine that the dates of [the physician’s]

alleged breaches are ascertainable; therefore, we measure limitations from the

occurrences of the alleged breaches.”); Gilbert, 144 S.W.3d at 143 (“The [appellants’]

complaint is that [the physician] was negligent in not taking actions—testing, referrals

to specialists, proper examinations—that would have led to earlier discovery of [the

patient’s] cancer. Those events, or nonevents, occurred on specific ascertainable

dates.”). Simply, the failure to diagnose the illness on an ascertainable date permitted

the disease process to continue; that is not the result of a course of treatment but

rather the result of the datable act of the failure to diagnose.

       Thus, to save his suit from the bar of limitations by expanding on the

allegations in his petitions, Mr. Pignano turns to his third issue that Dr. Markowitz

testified that a later ascertainable departure occurred—one that would make his suit

timely. To support this theory, he argues that Dr. Markowitz opined that Dr. Cash

departed from the standard of care in 2016 by his delays in ordering a needle biopsy

of the mass once Dr. Cash determined that the procedure should be performed. We

have quoted Mr. Pignano’s summary-judgment response at length to show the basis

for this argument. The testimony referenced by Mr. Pignano does not support his

argument.

       Again, Dr. Cash’s counsel set the parameters of Dr. Markowitz’s opinions by

having him agree that his criticisms did not relate to what had occurred in 2016:

                                            21
      [Dr. Cash’s counsel]: But the criticism is not of the 2016 care, the two
      times in 2014 where he didn’t do the biopsy?

            [Dr. Markowitz]: Correct. Once he realized this was cancer[,] he
      went ahead and got the biopsy done. That’s what you do. And we
      would have done it, like I said, a little differently, but that’s [the] art of
      medicine. That I don’t go after people for.

Indeed, Dr. Markowitz conceded that he did not “have any issues or criticisms of

Dr. Cash specifically at the February 22nd 2016 visit as far as his care and treatment

go.” He also conceded that his opinion was “that what [Dr. Cash] did in February

2016 was appropriate . . . [but] definitely should have been done sooner.”

      The one snippet of testimony that Mr. Pignano offers to argue that

Dr. Markowitz opined that Dr. Cash’s February treatment was substandard fails to

carry the day. Mr. Pignano notes that Dr. Markowitz might have ordered additional

testing. But in the next breath Dr. Markowitz stated, “But that is small. I mean, I

would have done that differently[;] he did get a biopsy[,] and that was appropriate.” 7

      7
       In his opening brief and in his reply brief, Mr. Pignano argues that
Dr. Markowitz testified that “Dr. Cash’s care in its entirety was below the standard of
care.” We do not read the testimony cited in support of this statement to bear it out:

      Q. Okay. So as we sit here today, as of now, it is not your opinion that
      Dr Cash’s care in its entirety was below the standard of care, correct?

             A. I don’t think I can answer that question other than to say I
      believe without question that it was below the standard of care and the
      evaluation of a likely lung cancer.

And to the extent that his testimony could be read to criticize the entirety of
Dr. Cash’s care, the other testimony of Dr. Markowitz that we cited demonstrates that
he tied his opinions about the failure to meet the standard of care to particular events.

                                           22
      Pivotally, Dr. Markowitz’s deposition testimony does not contain an opinion

that Dr. Cash breached the standard of care because of the gap in time between

Dr. Cash’s ordering the needle biopsy in February 2016 and the time it was conducted

in April 2016. Though Dr. Markowitz testified that this was his “biggest” concern, he

could not attribute the gap to anyone’s action or inaction and did not opine that it was

a violation of the standard of care. Dr. Markowitz’s deposition testimony was as

follows: “Like I said, my biggest concern right here is what happened between

February 22nd and April 26th, that is a two-month gap. We would do that[,] and I

don’t recall what the issue was for getting the biopsy, why it took two months.”

      Nor does the additional testimony that Mr. Pignano cites on the issue of the

two-month delay reference a departure from the standard of care:

      [Dr. Cash’s counsel]: To follow back up on that, she phrased it as
      damage, what damage occurred, but what harm actually occurred to Mr.
      Pignano by the two-month delay?

             [Dr. Markowitz]: You don’t know. I mean, the likelihood that it
      changed and . . . suddenly he had metastasis, it is a low likelihood, but I
      have much more of a sense of urgency once you know, okay, this is
      going to be cancer, we need to find out exactly what kind it is [,]and we
      need to complete a staging because if he is still candidate for curative
      intense surgery[,] we need to get there.

      Also, the next question and answer—not referenced by Mr. Pignano—

reinforces that Dr. Markowitz is not claiming that the delay is a breach of the standard

of care or something that harmed Mr. Pignano:

      [Dr. Cash’s counsel]: [W]hat I heard you say[—]and I don’t want to put
      words in your mouth[—]is that you are not aware of any harm befalling

                                          23
       the patient because of that two months, you’d certainly like to see things,
       but you can’t say he had no involvement because of the two-month
       delay or metastasis because of the two-month delay?

              [Dr. Markowitz]: You are correct. Yes, I am not inferring that
       everything was cool[,] and then two months later[,] it went to hell. That
       is not a fair statement.

       This testimony does not reference a standard of care. Even if viewed as a

criticism of Dr. Cash, we do not know if Dr. Markowitz is offering anything other

than his personal opinion on the issue. Even if we could discern an opinion that a

departure from the standard of care occurred, Dr. Markowitz’s deposition

testimony—that the likelihood is low that the cancer suddenly metastasized in the

two-month period—disables any argument that there is a reasonable medical

probability that this breach caused harm to Mr. Pignano. See Jelinek v. Casas, 328

S.W.3d 526, 532–33 (Tex. 2010) (stating that in order to meet the legal-sufficiency

standard in medical malpractice cases, “plaintiffs are required to adduce evidence of a

‘reasonable medical probability’ or ‘reasonable probability’ that their injuries were

caused by the negligence of one or more defendants, meaning simply that it is ‘more

likely than not’ that the ultimate harm or condition resulted from such negligence”).

This is simply not sufficient to constitute a scintilla of evidence raising a fact issue that

Dr. Cash departed from the standard of care in 2016 or that the departure caused

injury to Mr. Pignano, even if he had predicated his suit on that claim. 8

       Mr. Pignano pleaded that the open-courts provision of the Texas Constitution
       8

saved his claim from being barred by limitations. Dr. Cash moved for a traditional

                                             24
      We have considered all the summary-judgment evidence by analyzing all the

excerpts of Dr. Markowitz’s deposition that were offered and the medical records of

Mr. Pignano’s care. The summary-judgment record establishes two things. The date

of the breach of or departure from the standard in this case is ascertainable.

According to Dr. Markowitz, it occurred in November 2014 when Dr. Cash departed

from the standard of care by not ordering a needle biopsy after the second CT scan

showed that the mass was still present. Thus, Mr. Pignano cannot rely on a course of

treatment to save his claim from the bar of limitations. Nor can Mr. Pignano rely on

summary judgment and a no-evidence summary judgment on this issue. The First
Court of Appeals recently outlined the open-courts provision and how it may prevent
the operation of the statute of limitations from barring a health care liability claim as
follows:

      The Texas Constitution guarantees that persons bringing common-law
      claims will not unreasonably or arbitrarily be denied access to the courts.
      Tex. Const. art. I, § 13 (“All courts shall be open, and every person for
      an injury done him, in his lands, goods, person[,] or reputation, shall
      have remedy by due course of law.”); see also Thomas[ v. Jayakumar, No.
      01-14-00984-CV], 2016 WL 640629, at *3[ (Tex. App.—Houston [1st
      Dist.] Feb. 11, 2016, no pet.) (mem. op.)]. The open[-]courts provision,
      however, does not toll limitations. See Tenet Hosps. Ltd. v. Rivera, 445
      S.W.3d 698, 703 (Tex. 2014). Rather, unlike a tolling provision, which
      defers the accrual of a cause of action until the plaintiff knew or,
      exercising reasonable diligence, should have known of the facts giving
      rise to her claim, the open[-]courts provision merely gives a litigant a
      reasonable time to discover her injuries and file suit. Rivera, 445 S.W.3d
      at 703, Walters, 307 S.W.3d at 295.

Harris v. Kareh, No. 01-18-00775-CV, 2020 WL 4516878, at *6 (Tex. App.—Houston
[1st Dist.] Aug. 6, 2020, pet. denied) (mem. op.). Mr. Pignano’s brief does not present
any issue or argument that the open-courts provision saves his claim. Thus, we will
not address that provision’s impact on Mr. Pignano’s claim.

                                           25
Dr. Markowitz’s deposition to establish that he opined that there were departures

from the standard of care in 2016; the deposition cannot be read to support

Mr. Pignano’s argument that Dr. Markowitz opined that there was a later breach

because of the 2016 delay in conducting a third CT scan.9

       9
         Mr. Pignano also attached Dr. Markowitz’s expert report to his summary-
judgment response. “[A]n expert report [required to be filed as part of a health care
liability claim]: (1) is not admissible in evidence by any party; (2) shall not be used in a
deposition, trial, or other proceeding; and (3) shall not be referred to by any party
during the course of the action for any purpose.” Tex. Civ. Prac. & Rem. Code Ann.
§ 74.351(k). We have held that it is improper to use an expert report as summary-
judgment evidence but that the use of the report is a defect of form to which an
objection must be made. See Coleman v. Woolf, 129 S.W.3d 744, 747–50 (Tex. App.—
Fort Worth 2004, no pet.). Here, Dr. Cash objected to the use of the report as
incompetent summary-judgment evidence, the trial court overruled the objection, and
Dr. Cash does not challenge that ruling on appeal. But whether the report may be
considered as summary-judgment evidence, we agree with Dr. Cash that
Dr. Markowitz clarified his opinions during his deposition, and we rely on his
deposition testimony as the statement of what departures from the standard of care
occurred.

                                            26
                               IV. Conclusion

      We overrule Mr. Pignano’s first issue that generally attacks the trial court’s

grant of summary judgment. We also overrule Mr. Pignano’s more specific second

and third issues claiming that a course of treatment by Dr. Cash made Mr. Pignano’s

suit timely and that Dr. Markowitz dated the ascertainable departure from the

standard of care in 2016 such that it made the suit timely. We affirm the summary

judgment that Mr. Pignano take nothing from Dr. Cash.

                                                   /s/ Dabney Bassel

                                                   Dabney Bassel
                                                   Justice

Delivered: January 6, 2022

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