Court Opinion

ID: 4702886
Source: CourtListenerOpinion
Date Created: 2021-07-12 17:19:49.047891+00
Date Added: 2024-06-11T08:06:27.438972
License: Public Domain

IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON

 MARI YVONNE DAVIES,
                                            No. 80854-1-I
                          Appellant,
                                            DIVISION ONE
               v.

 MULTICARE HEALTH SYSTEM, a                 PUBLISHED OPINION
 Washington corporation d/b/a GOOD
 SAMARITAN HOSPITAL, and MT.
 RAINIER EMERGENCY
 PHYSICIANS, PLLC; MICHAEL
 HIRSIG, M.D.,

                         Respondents.

      MANN, C.J. — In this medical malpractice action, Mari Davies appeals the trial

court’s order dismissing her informed consent claim on summary judgment. Davies also

appeals the judgment entered on a jury verdict finding the defendants not negligent.

Davies argues that the trial court erred by giving an exercise of judgment jury

instruction, and preventing her expert neurosurgeon from testifying at trial regarding the

standard of care for an emergency room physician. We reverse summary judgment

dismissal of Davies’s informed consent claim and remand for trial. We otherwise affirm.

                                             FACTS

      On August 23, 2017, Davies was involved in a single-car rollover crash. She had

no memory of the accident. Paramedics extracted Davies from the vehicle, placed her
No. 80854-1-I/2

on a backboard and in a cervical collar, and transported her by ambulance to Good

Samaritan Hospital in Puyallup. Davies reported pain in her neck, back, left shoulder,

and tingling in her left arm. She also had preexisting high blood pressure, pneumonia,

kidney stones, and diabetes.

      Dr. Michael Hirsig, the attending physician at the Good Samaritan emergency

room, saw Davies upon arrival. Dr. Hirsig conducted a physical exam and ordered

laboratory tests, an electrocardiogram (EKG), and computerized tomography (CT)

scans of her head, cervical spine, abdomen, and pelvis. Dr. Scott Henneman, the

radiologist who interpreted the CT scans, noted fractures of Davies’s cervical spine at

the C3 level. At Dr. Henneman’s recommendation, Dr. Hirsig contacted Dr. William

Morris, a neurosurgeon who often consults by telephone with other physicians in the

MultiCare Health System. After reviewing the images, Dr. Morris told Dr. Hirsig that the

fractures appeared stable and did not require surgery. Neither Dr. Henneman nor Dr.

Morris identified a fracture through the transverse foramen, which would increase the

risk of injury to the vertebral artery. Dr. Morris recommended that Davies be placed in a

cervical collar for 8 weeks, with a follow-up CT scan to check for healing and alignment.

Dr. Morris’s progress notes indicate that he was under the impression Davies would be

transferred to Tacoma General Hospital for observation by the trauma team.

      Dr. Hirsig initially informed Davies and her family that she had sustained a neck

fracture and would likely be transferred to the trauma unit at Tacoma General Hospital.

However, after the consultation with Dr. Morris, Dr. Hirsig advised that Davies did not

need hospitalization or surgery and could be discharged with a hard cervical collar, with

follow-up on an outpatient basis. Dr. Hirsig testified that he asked the family whether

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No. 80854-1-I/3

they were comfortable taking her home, and they said yes. 1 Dr. Hirsig prescribed pain

medication, nausea medication, a muscle relaxant, and a different antibiotic for her

pneumonia, and sent Davies home without further treatment or testing.

        The following day, Davies’s daughter took Davies to her primary care physician,

Dr. Andrew Larsen, for a follow up visit. Davies’s vital signs were unstable and she had

severe neck pain made worse by coughing. Dr. Larsen arranged for Davies to be

immediately transported to Providence St. Peter hospital for direct admission. While

awaiting transport, Davies suffered a stroke in Dr. Larsen’s office. Her stroke was later

determined to have been caused by a vertebral artery dissection sustained when her

neck fractured during the accident. Davies was hospitalized for approximately three

weeks and now resides at an assisted living facility.

        On May 31, 2018, Davies filed suit against MultiCare alleging (1) medical

negligence, (2) failure to obtain informed consent, and (3) corporate negligence.

Davies alleged that MultiCare and its employees or agents breached the standard of

care by failing to admit or transfer her for observation and treatment or by failing to

order additional imaging, such as a CT angiography (CTA) scan, to check for vertebral

artery dissection prior to discharge. Dr. Hirsig was allowed to intervene on September

14, 2018. On February 13, 2019, Davies filed an amended complaint and added Dr.

Hirsig’s employer, Mt. Rainier Emergency Physicians PLLC, as a defendant.

        On cross-motions for partial summary judgment, the trial court dismissed

Davies’s informed consent claim, and the case proceeded to trial on the negligence

claims.

        1Davies’s daughter Melissa Brononske disputed Dr. Hirsig’s testimony that the family agreed with
the discharge decision.

                                                   3
No. 80854-1-I/4

       At trial, the jury heard expert testimony regarding whether Dr. Hirsig breached

the standard of care of an emergency medicine physician. Dr. Hirsig testified that he

considered and rejected a diagnosis of vertebral artery dissection and that his care of

Davies met the standard of care. Dr. Raymond Moreno, an emergency medicine

physician who practices in Portland, Oregon, testified that Dr. Hirsig “absolutely met the

standard of care” by performing a broad workup exam, identifying Davies’s neck

fracture, and consulting with Dr. Morris prior to making a disposition decision. Dr.

Moreno further testified that the standard of care in Washington and Oregon does not

require a CTA scan for every C3 fracture.

       Davies’s expert Dr. Carrie Tibbles, an emergency physician at Beth Israel

Deaconess Medical Center in Boston, testified that her hospital routinely obtains a scan

of the vertebral arteries for patients with neck fractures and that when an emergency

room physician identifies vertebral artery dissection as a differential diagnosis, the

standard of care requires a CTA scan. She further testified that it was not safe for

Davies to go home that day.

       Davies also sought to call Dr. Clara Harraher, a neurosurgeon who practices in

California, to testify that Dr. Morris breached the standard of care for a neurosurgeon

and that Dr. Hirsig breached the standard of care for an emergency room physician.

At trial, following the defendants’ foundational objection, the trial court ruled that Dr.

Harraher could testify to a neurosurgeon’s standard of care but not an emergency

medicine doctor’s standard of care.

       The jury also heard expert testimony regarding whether Dr. Morris breached the

standard of care for a neurosurgeon in his consultation with Dr. Hirsig. Dr. Morris

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No. 80854-1-I/5

described his practice of consulting with other MultiCare physicians regarding

neurological issues, and testified that he met the standard of care. Neurologists Dr.

David Lundin and Dr. Jeffrey Johnson testified that Dr. Morris’s consultation met the

standard of care and that not all C3 fractures require vascular imaging.

        Dr. Harraher testified that Dr. Morris’s consultation with Dr. Hirsig did not meet

the standard of care for a neurosurgeon. She testified that the standard of care

required a CTA in this case given the nature of Davies’s injuries and the risk of vertebral

artery injury.

        Over Davies’s objection, the court gave the following “exercise of judgment” jury

instruction:

        A physician is not liable for selecting one or two or more alternative
        diagnoses, if, in arriving at the judgment to make the particular diagnosis,
        the physician exercised reasonable care and skill within the standard of
        care the physician was obliged to follow.

        The jury returned a special verdict finding Dr. Hirsig and MultiCare not negligent,

and therefore did not reach the issues of proximate cause or damages. The trial court

entered judgment against Davies. Davies appealed.

                                               ANALYSIS

        A. Informed Consent

        Davies first argues that the trial court erred in dismissing her informed consent

claim on summary judgment. 2 This court reviews summary judgment orders de novo.

Seybold v. Neu, 105 Wn. App. 666, 675, 19 P.3d 1068 (2001). Summary judgment is

appropriate if there are no genuine issues of material fact and the moving party is

        2 In her opening brief, Davies expressly states that her corporate negligence claim against
MultiCare and vicarious liability claim against Mt. Rainier were not at issue in this appeal. The claims are
therefore abandoned.

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No. 80854-1-I/6

entitled to judgment as a matter of law. CR 56(c). All evidence and reasonable

inferences are construed in the light most favorable to the nonmoving party. Keck v.

Collins, 184 Wn.2d 358, 368, 357 P.3d 1080 (2015).

       “Informed consent and medical negligence are distinct claims that apply in

different situations. While there is some overlap, they are two different theories of

recovery with independent rationales.” Anaya Gomez v. Sauerwein, 180 Wn.2d 610,

617, 331 P.3d 19 (2014). “Informed consent allows a patient to recover damages from

a physician even though the medical diagnosis or treatment was not negligent.”

Backlund v. Univ. of Wash., 137 Wn.2d 651, 659, 975 P.2d 950 (1999). To prove failure

to obtain informed consent, a plaintiff must show:

       (a) That the health care provider failed to inform the patient of a material
       fact or facts relating to the treatment;

       (b) That the patient consented to the treatment without being aware of or
       fully informed of such material fact or facts;

       (c) That a reasonably prudent patient under similar circumstances would
       not have consented to the treatment if informed of such material fact or
       facts;

       (d) That the treatment in question proximately caused injury to the patient.

RCW 7.70.050(1).

       Washington’s informed consent statute is “generally based on the policy

judgment that patients have the right to make decisions about their own medical

treatment.” Backlund, 137 Wn.2d at 663. “A necessary corollary to this principle is that

the individual be given sufficient information to make an intelligent decision.” Smith v.

Shannon, 100 Wn.2d 26, 29, 666 P.2d 351 (1983). “The concept of patient

decisionmaking regarding treatment has sometimes been described as ‘patient

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No. 80854-1-I/7

sovereignty.’” Backlund, 137 Wn.2d at 663 (quoting Archer v. Galbraith, 18 Wn. App.

369, 377 n.2, 567 P.2d 1155 (1977)). “[I]t is for the patient to evaluate the risks of

treatment and that the only role to be played by the physician is to provide the patient

with information as to what those risks are.” Smith, 100 Wn.2d at 30.

        In Gates v. Jensen, 92 Wn.2d 246, 250, 595 P.2d 919 (1979), a case decided

prior to the adoption of RCW 7.70.050(1), our Supreme Court addressed whether the

doctrine of informed consent requires a physician to inform a patient of a bodily

abnormality and diagnostic procedures that were available to determine the significance

of the abnormality. In Gates, the plaintiff complained of difficulty in focusing, blurring,

and gaps in vision. Gates consulted an ophthalmologist, Dr. Hargiss, who took eye

pressure readings that indicated her eye pressure was in the borderline area for

glaucoma. Dr. Hargiss did not conduct further tests and informed Gates that he had

checked for glaucoma but found everything all right. Dr. Hargiss did not inform Gates

that the high pressure put her at risk for glaucoma, nor that he had available two

additional simple, inexpensive, and risk free diagnostic tests for glaucoma. 3 Gates, 92

Wn.2d at 247-48.

        At trial, Gates requested jury instructions on the doctrine of informed consent,

which the trial court denied. The Supreme Court reversed, explaining:

        Important decisions must frequently be made in many non-treatment
        situations in which medical care is given, including procedures leading to a
        diagnosis, as in this case. These decisions must all be taken with the full
        knowledge and participation of the patient. The physician's duty is to tell
        the patient what he or she needs to know in order to make them. The
        existence of an abnormal condition in one's body, the presence of a high
        risk of disease, and the existence of alternative diagnostic procedures to

        3 The first was to use standard drops for dilating the pupils to obtain a better view of the optic
nerve. The second was to have Gates take a “visual field examination” to determine if she had suffered
any loss in vision. Gates, 92 Wn.2d at 248.

                                                     7
No. 80854-1-I/8

       conclusively determine the presence or absence of that disease are all
       facts which a patient must know in order to make an informed decision on
       the course which future medical care will take.

Gates, 92 Wn.2d at 250-51.

       At the other end of the spectrum, our Supreme Court has also held that a claim

for misdiagnosis does not support a claim for informed consent where the treating

physician is unaware of alternative diagnoses. Backlund, 137 Wn.2d at 661. In

Backlund, the defendant physician diagnosed a newborn infant with jaundice and chose

to treat the condition with phototherapy rather than a blood transfusion. 137 Wn.2d at

662. The phototherapy treatment was not successful and the infant suffered brain

damage and died. The infant’s parents brought medical malpractice and informed

consent claims against the treating physician and the University of Washington. A jury

exonerated the treating physician and University from negligence for continuing to treat

with phototherapy rather than a transfusion. Backlund, 137 Wn.2d at 653. The trial

court found that the possibility of a transfusion was a “material fact” of which the

Backlunds were not aware and thus supported their claim for lack of informed consent.

The court concluded, however, that the Backlunds failed to prove that a reasonably

prudent person would have consented to the treatment even if informed.

       On appeal, the University argued that the Backlunds’ claim for lack of informed

consent failed as a matter of law because the jury had exonerated the physician from

liability for negligence. Our Supreme Court first recognized that negligence and

informed consent are “alternative methods of imposing liability on a health care

practitioner.” And that “[i]nformed consent allows a patient to recover damages from a

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No. 80854-1-I/9

physician even though the medical diagnosis or treatment was not negligent.”

Backlund, 137 Wn.2d at 659. The court explained further:

       A physician who misdiagnoses the patient’s condition, and is therefore
       unaware of an appropriate category of treatments or treatment
       alternatives, may properly be subject to a negligence action where such
       misdiagnosis breaches the standard of care, but may not be subject to an
       action based on failure to secure informed consent.

Backlund, 137 Wn.2d at 661.

       The Supreme Court disagreed with the University’s position that the Backlunds’

informed consent claim failed as a matter of law. The court concluded that even though

the jury found no negligence, because there were no facts suggesting that the treating

physician was unaware of the transfusion alternative, the “trier of fact might still have

found he did not sufficiently inform the patient of risks and alternatives in accordance

with RCW 7.70.050.” Backlund, 137 Wn.2d at 662. The Supreme Court agreed with

the trial court, however, that the Backlunds failed to demonstrate that a reasonably

prudent person would have consented to the treatment even if informed. Backlund,

137 Wn.2d at 668.

       More recently, in Anaya Gomez, our Supreme Court again discussed the

interplay between informed consent claims and negligence claims based on

misdiagnosis. 180 Wn.2d at 613. In Anaya Gomez, the physician did not alert a

diabetic patient to preliminary blood test results indicating that she had a yeast infection,

having concluded that it was a false positive because the patient indicated that she was

feeling better. 180 Wn.2d at 613-14. A later test confirmed the presence of a severe

yeast infection. Anaya Gomez, 180 Wn.2d at 615. After the patient died, her personal

representative brought claims for negligence and informed consent. The trial court

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No. 80854-1-I/10

dismissed the informed consent claim on summary judgment, and the Supreme Court

affirmed.

       The Supreme Court began by setting forth the issue before it: “[i]n determining

which theory of recovery is available, the issue is whether this is a case of misdiagnosis

subject only to negligence or if the facts also support an informed consent claim.”

Anaya Gomez, 180 Wn.2d at 617. The court explained that it was significant in Gates

that the ophthalmologist had “two additional diagnostic tests for glaucoma which are

simple, inexpensive, and risk free.” Anaya Gomez, 180 Wn.2d at 621 (quoting Gates,

92 Wn.2d at 248). Consequently, the “choice the ophthalmologist could have put to

Mrs. Gates was whether to do the additional testing in light of her borderline test result.

Given the small cost and effort of those tests, the decision was relatively easy.” Anaya

Gomez, 180 Wn.2d at 621.

       The court distinguished the situation before it from the situation in Gates,

determining that “[t]his case is different from Gates because there was nothing else that

Dr. Sauerwein could have done. Informing a patient about a likely erroneous lab result

gives the health care provider nothing to “‘put to the patient in the way of an intelligent

and informed choice.’” Anaya Gomez, 180 Wn.2d at 622 (quoting Keogan v. Holy

Family Hospital, 95 Wn.2d 306, 330, 622 P.2d 1246 (1980) (Hicks, J., concurring in

part, dissenting in part)). Because Gates did not apply, the court applied the “Backlund

rule” and affirmed the trial court’s dismissal of the informed consent claim as a matter of

law. Anaya Gomez, 180 Wn.2d at 623.

       Important here, the court confirmed that Gates has not been overruled. Anaya

Gomez, 180 Wn.2d at 623. The court explained:

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No. 80854-1-I/11

       Backlund and Keogan state the general rule of when a plaintiff can make
       an informed consent claim. The Gates court allowed the informed consent
       claim based on a unique set of facts that are distinguishable from this
       case. Under Gates, there may be instances where the duty to inform
       arises during the diagnostic process, but this case does not present such
       facts. The determining factor is whether the process of diagnosis presents
       an informed decision for the patient to make about his or her care. Dr.
       Sauerwein’s knowledge of the test result provided no treatment choice for
       Mrs. Anaya to make.

Anaya Gomez, 180 Wn.2d at 623.

       Here, like Gates, and unlike Anaya Gomez, Davies presented evidence at

summary judgment supporting that once she was correctly diagnosed with a cervical

fracture, there were additional tests available as part of her initial diagnoses—namely a

CT angiography (CTA) scan—to check for vertebral artery dissection prior to discharge.

Davies’s medical experts testified that vertebral artery injury is a “common” and “well

known” occurrence following cervical spine fractures. As Davies’s expert Dr. Harraher

testified in deposition:

       Q.     Doctor, if I understand you correctly, the reason that there is a
              whole body of literature on the fact that you should screen for
              vertebral artery injury when you have a cervical spine fracture is
              because those are commonly found?

       A.     Yes.

       Q.     They are commonly found together and commonly missed; right?

       A.     Correct.

Davies’s expert Dr. Becker similarly testified:

       Q.     What’s the basis of the opinion that this fracture should have
              prompted imaging of her cervical arterial vessels?

       A.     It’s well-known in the trauma literature that the mechanism of injury
              that leads to a cervical fracture is one that can also lead to a
              cervical arterial dissection, and there are criteria that have been

                                             11
No. 80854-1-I/12

             created that suggest that if someone has such a fracture that they
             should have cervical arterial imaging.

      Davies further presented evidence at summary judgment that had she undergone

a CTA, her vertebral artery dissection would have been diagnosed and a different

treatment regimen other than sending her home in a neck brace would have been

initiated, preventing her subsequent stroke. Dr. Becker explained:

      Q.     And then what do you believe that the treatment of either aspirin,
             Plavix, or heparin would have prevented, if anything?

      A.     I believe that it would have prevented her subsequent stroke.

      Q.     And what’s the basis of the opinion that aspirin, Plavix, or heparin
             would have prevented her stroke?

      A.     If you look at all the studies that have been done of antithrombotic
             therapy in arterial dissections, they are all highly effective with very
             few patients ever going on to have a recurrent event, or an event if
             it was a dissection that was picked up kind of prophylactically.

      Davies’s medical expert, Dr. Tibbles, agreed:

      Q.     Okay, as far as causation opinions go in this case, you offered
             causation testimony that had Doctor Hirsig and Doctor Morris
             somehow through that process admitted her to trauma service, then
             she would not have suffered a stroke? Did I understand your
             causation opinion?

      A.     I believe more likely than not if she had received proper
             comprehensive care from a trauma team, including a neurosurgeon
             and the proper evaluation of her condition, that more likely than not
             they would have done the right thing and worked up the cervical
             spine fracture in the proper way, which would have included
             evaluation of the vessels.

             Had the vessels been evaluated, the dissection seen, the
             potential—there’s a window there to treat the stroke—treat the
             potential complications of stroke and therefore prevent the stroke.

      Viewed in the light most favorable to Davies, as we must, her experts agree that

had she undergone a CTA, she would have been diagnosed with a vertebral artery

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No. 80854-1-I/13

dissection, which then would have been treated, preventing her from having a stroke the

next day. Davies was never advised of the risk of a vertebral artery dissection or the

availability of a CTA scan to look for the injury which would have led to a different

treatment. Like Gates, and unlike Anaya Gomez, there were diagnostic and treating

procedures available to the treating doctors. As the Supreme Court recognized in

Anaya Gomez, “the determining factor is whether the process of diagnosis presents an

informed decision for the patient to make about his or her care.” 180 Wn.2d at 623.

Here, there was. Summary judgment dismissal of Davies’s informed consent claim was

erroneous.

       B. Jury Instruction

       Davies argues next that the trial court erred by giving an exercise of judgment

instruction to the jury because the instruction is appropriate only where there is

evidence that the physician makes a choice between alternative diagnoses. Davies

contends that the trial record is devoid of evidence to support the jury’s determination

that Dr. Hirsig and MultiCare made such a choice. We disagree.

       We review a decision on whether to give an exercise of judgment instruction for

abuse of discretion. Fergen v. Sestero, 174 Wn. App. 393, 396, 298 P.2d 782 (2013),

aff’d, 182 Wn.2d 794, 803, 346 P.3d 708 (2015). This is a fact specific inquiry. Fergen,

182 Wn.2d at 803. Jury instructions are generally sufficient if they: (1) are supported by

the evidence; (2) allow each party to argue its theory of the case; and (3) properly

inform the trier of fact of the applicable law when all the instructions are read together.

Fergen, 182 Wn.2d at 803.

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No. 80854-1-I/14

        Our Supreme Court considered use of the exercise of judgment instruction most

recently in Fergen. Fergen involved a consolidated appeal from two medical

malpractice trials in which the trial court gave an exercise of judgment instruction and

the jury returned a verdict for the defendants. In the first case, Fergen, Paul Fergen

presented to the physician with a lump on his ankle. After performing a physical

examination and taking an x-ray of the ankle, the physician diagnosed the lump as a

benign cyst and referred him to an orthopedic office without conducting further testing.

Fergen, 182 Wn.2d at 799. In doing so, the physician chose to forgo an ultrasound on

Fergen’s ankle, which may have found the rare form of cancer that began in Fergen’s

ankle and resulted in his death. Fergen, 182 Wn.2d at 799-800.

        In the second case, Appukuttan v. Overlake Medical Center, Anil Appukuttan

injured his leg during a soccer game. He visited the emergency room five times due to

increasing pain in his leg. Multiple physicians examined him, but none measured the

pressure in his leg to rule out compartment syndrome, instead believing his symptoms

indicated a different diagnosis. Fergen, 182 Wn.2d at 801. Appukuttan

“suffered permanent foot drop injury as a result of the failure to diagnose and treat his

compartment syndrome.” Fergen, 182 Wn.2d at 801.

        In a split 5-4 decision, the majority first concluded that the instruction was

supported under Washington law. The court also rejected an invitation to overrule

precedent and abandon use of the instruction as unnecessary. Fergen, 182 Wn.2d at

803-05, 809-11. 4 Turning to the merits, the court held that for Fergen, the physician

        4 The dissent concluded that the exercise of judgment law was rooted in the discredited “error of
judgment” instruction and not supported by Washington law; that the instruction is confusing, unfair, and
inconsistent with the modern practice of giving neutral instructions; and that the instruction should be

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No. 80854-1-I/15

“had a choice between referring Fergen to a specialist or not . . . ordering an X ray or

not[, and] ordering follow up testing or not.” Fergen, 182 Wn.2d at 808. For

Appukuttan, the court concluded that the physicians decided that the pressure test “was

unnecessary because their physical examination did not indicate that compartment

syndrome was the diagnosis.” Fergen, 182 Wn.2d at 809.

       In reaching its holding, the Supreme Court explained:

       In Washington, an exercise of judgment instruction is justified when (1)
       there is evidence that the physician exercised reasonable care and skill
       consistent with the applicable standard of care in formulating his or her
       judgment and (2) there is evidence that the physician made a choice
       among multiple alternative diagnoses (or courses of treatment).

Fergen, 182 Wn.2d at 806. As this court recently summarized:

       Specifically, a court should give the instruction only when the physician
       presents sufficient evidence that they made a choice between two or more
       alternative, “reasonable [and] medically acceptable” treatment plans or
       diagnoses. The court should not give the instruction “simply if a physician
       is practicing medicine at the time.” The Fergen Court also recognized an
       exception to the instruction's use: A court should not give the exercise of
       judgment instruction in cases focusing on the inadequate skills of the
       physician.

Needham v. Dreyer, 11 Wn. App. 2d 479, 488-89, 454 P.3d 136, review denied, 195

Wn.2d 1017, 461 P.3d 1201 (2020) (quoting Fergen, 182 Wn.2d at 708).

       Applying the Fergen standard to the testimony at trial, we conclude that the

exercise of judgment instruction in this case was proper. Dr. Hirsig testified that he

considered the possibility that Davies could have a vertebral artery dissection in making

his differential diagnosis. After consulting with Dr. Henneman, the neuroradiologist that

reviewed Davies’s CT scan, he learned that she had a C3 fracture of her cervical spine,

disapproved of. Fergen, 182 Wn.2d at 812-26 (Stephens, J., dissenting). While the dissent in Fergen is
compelling, we are bound by the majority opinion.

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No. 80854-1-I/16

but Dr. Henneman did not identify a fracture of the transverse foramen. Such a fracture

would have heightened Dr. Hirsig’s awareness that there could be an injury to the

vertebral artery. Consequently, Dr. Hirsig chose not to request a CTA to test for

vertebral artery dissection because he believed the likelihood she did not have one

outweighed the likelihood she did not. He summarized:

       with my assessment of the patient, with her physical findings and with her
       exam and with all the information I had, and in speaking to the
       neuroradiologist as well as the neurosurgeon [Dr. Morris], the
       consensus—I felt like that [vertebral arterial dissection] was not something
       I needed to further assess.

       Neurosurgeon Dr. Morris, also testified that in consulting with Dr. Hirsig, he

reviewed Ms. Davies’s CT images and specifically looked for a fracture of the

transverse foramen in the C3 area because the risk of injury to the vertebral artery is

higher with such a fracture. Dr. Morris observed no sign of a fracture to the transverse

foramen. And finally defense experts testified that both physicians met the standard of

care in deciding not to order a CTA scan. Consistent with the standard set out in

Fergen, the testimony supported that Dr. Hirsig and Dr. Morris, considered the

possibility of a diagnosis of vertebral arterial dissection and made a choice not to pursue

further.

       Davies argues that this court’s recent opinion in Needham compels reversal.

Needham is distinguishable. In Needham, the plaintiff visited his primary care doctor

complaining of breathing problems and gastrointestinal issues. 11 Wn. App. 2d at 481.

The physician treated him for his preexisting HIV and diarrhea, but did not address his

breathing problems. Needham, 11 Wn. App. at 481. Several days later he was found

unconscious in cold weather, resulting in frostbite that required amputation. Needham,

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No. 80854-1-I/17

11 Wn. App. 2d at 481. The plaintiff sued his physician and the clinic alleging medical

negligence as the cause of his injuries. Needham, 11 Wn. App. 2d at 481-82. Over his

objection, the trial court gave an exercise of judgment instruction and the jury entered a

verdict for the defense. Needham, 11 Wn. App. 2d at 486. This court, applying Fergen,

held that the exercise of judgment instruction was improper because there was no

evidence that the physician actually made a choice in diagnosing or treating his

breathing problems. But here, unlike Needham, there was evidence that the physicians

considered and actively chose among alternative diagnoses and treatment plans.

       We conclude that based on the standard approved in Fergen and the testimony

presented, the trial court did not abuse its discretion in giving the exercise of judgment

instruction.

       C. Expert Witness

       Davies argues finally that the trial court abused its discretion by preventing Dr.

Harraher, a neurosurgeon, from testifying regarding the standard of care for Dr. Hirsig,

an emergency room physician. We agree, but conclude the error was harmless.

       We review the decision to exclude an expert witness’s testimony for abuse of

discretion. Driggs v. Howlett, 193 Wn. App. 875, 896, 371 P.3d 61 (2016). Discretion is

abused if it is exercised on untenable grounds or for untenable reasons. Morrin v.

Burris, 160 Wn.2d 745, 753, 161 P.3d 956 (2007).

       “[E]xpert testimony will generally be necessary to establish the standard of care

and proximate cause required in medical malpractice cases.” Berger v. Sonneland, 144

Wn.2d 91, 111, 26 P.3d 257 (2001). The plaintiff must show that the health care

provider “failed to exercise that degree of care, skill, and learning expected of a

                                            17
No. 80854-1-I/18

reasonably prudent health care provider at that time in the profession or class to which

he or she belongs, in the state of Washington, acting in the same or similar

circumstances.” RCW 7.70.040(1).

       Only experts who practice in the same field or have expertise in the relevant

specialty may establish the standard of care. McKee v. Am. Home Prods., Corp., 113

Wn.2d 701, 706, 782 P.2d 1045 (1989). “The scope of the expert's knowledge, not his

or her professional title, should govern ‘the threshold question of admissibility of expert

medical testimony in a malpractice case.’” Hill v. Sacred Heart Med. Ctr., 143 Wn. App.

438, 447, 177 P.3d 1152 (2008) (quoting Pon Kwock Eng v. Klein, 127 Wn. App. 171,

172, 110 P.3d 844 (2005)). “A physician with a medical degree is qualified to express

an opinion on any sort of medical question, including questions in areas in which the

physician is not a specialist, so long as the physician has sufficient expertise to

demonstrate familiarity with the procedure or medical problem at issue in the medical

malpractice action.” Hill, 143 Wn. App. at 447 (quoting Morton v. McFall, 128 Wn. App.

245, 253, 115 P.3d 1023 (2005)). When experts are from a different school of

medicine, the testimony should be allowed “(1) where the methods of treatment in the

defendant’s school and the school of the witness are the same, (2) where the method of

treatment in the defendant’s school and the school of the witness should be the same,

or (3) the testimony of a witness is based on knowledge of the defendant’s own school.”

Leaverton v. Cascade Surgical Partners, P.L.L.C., 160 Wn. App. 512, 519, 248 P.3d

136 (2011).

       We conclude that Dr. Harraher had sufficient expertise in the procedures and

medical problem at issue to testify regarding the standard of care in Davies’s case. Dr.

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Harraher completed a cerebrovascular fellowship at Stanford, including work regarding

the vertebral artery. She testified that she has substantial emergency room experience,

including the care and treatment of patients with neck fractures and the decision to

order a CTA scan. Similarly, in Eng, this court held that an infectious disease doctor

was qualified to testify regarding a neurosurgeon’s failure to diagnose meningitis, where

the expert’s knowledge of the medical problem was uncontested and the defendant’s

method and failure to properly diagnose was not particularized to his neurological

specialty.

       However, even if the trial court erred in excluding this testimony, reversal is not

required because the error was harmless. The test for harmless error is whether there

is a reasonable probability that the error materially affected the outcome of the trial.

Frantom v. State, 12 Wn. App. 2d 953, 959, 460 P.3d 1100 (2020). “A factor to

consider when determining harmless error is whether excluded evidence involved

cumulative evidence.” Driggs, 193 Wn. App. at 903.

       As an offer of proof, counsel for Davies stated that Dr. Harraher would have

testified that Dr. Hirsig should not have discharged Davies due to the mechanism of her

injury and the other clinical problems that she was having. But Davies’s emergency

medicine expert, Dr. Tibbles, testified extensively as to her opinion that Davies was not

safe to go home and should not have been discharged. Because the excluded

testimony was cumulative, reversal is not required.

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      We reverse summary judgment dismissal of Davies’s informed consent claim and

remand for trial. We otherwise affirm.

WE CONCUR:

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