Court Opinion

ID: 5124097
Source: CourtListenerOpinion
Date Created: 2021-11-08 10:15:34.69924+00
Date Added: 2024-06-11T08:22:38.476380
License: Public Domain

In the
                      Court of Appeals
              Second Appellate District of Texas
                       at Fort Worth
                   ___________________________
                        No. 02-20-00190-CV
                   ___________________________

COLUMBIA MEDICAL CENTER OF ARLINGTON SUBSIDIARY, L.P. D/B/A
MEDICAL CITY ARLINGTON; AND HCA, INC. D/B/A HCA HEALTHCARE,
                         Appellants

                                    V.

  J.B., JR., INDIVIDUALLY AND AS REPRESENTATIVE OF THE ESTATE OF
I.B., DECEASED, AND NEXT FRIEND OF J.B. AND L.B., MINORS, Appellee

                 On Appeal from the 17th District Court
                        Tarrant County, Texas
                    Trial Court No. 017-312807-19

               Before Sudderth, C.J.; Kerr and Birdwell, JJ.
                 Memorandum Opinion by Justice Kerr
                           MEMORANDUM OPINION

      In this healthcare-liability case, a hospital and another healthcare-related

company appeal the trial court’s refusal to dismiss, based on an allegedly defective

expert report, the plaintiff’s medical-negligence claims against them. See Tex. Civ.

Prac. & Rem. Code Ann. §§ 74.001–.507 (the Texas Medical Liability Act, or TMLA).

Raising two substantive issues, 1 Columbia Medical Center of Arlington Subsidiary,

L.P. d/b/a Medical City Arlington and HCA, Inc. d/b/a HCA Healthcare

(collectively, the Hospital) argue that (1) the plaintiff’s medical expert lacked the

requisite qualifications to opine on standards of care for hospital policies and

procedures or gave only conclusory statements about his qualifications, and was also

unqualified to opine on causation; and, alternatively, (2) the expert’s opinions about

the Hospital’s breach of the allegedly applicable standards of care and about causation

were conclusory and did not represent a good-faith effort to comply with the TMLA’s

requirements. See id. § 74.351. We will reverse and remand to the trial court for further

proceedings.

      1
       A third issue argues simply that if we reverse as to Medical City, we should
reverse as to HCA on the same bases.

                                           2
                                   I. Background

      In February 2018, 35-year-old I.B. (“Irene”) fainted in a stairwell and was taken

by ambulance to the Hospital.2 She presented with symptoms consistent with a

pulmonary embolism (a blood clot in the lungs): chest pain, shortness of breath, and

severe syncope (fainting). An emergency-room doctor charted a primary impression

that Irene had suffered a heart attack, and she was admitted to the Hospital with that

presumptive diagnosis. A cardiologist performed a heart catheterization that showed

small plaque to the left anterior descending artery and diagnosed Irene with mild mid-

LAD plaque and atherosclerotic artery disease, with discharge set for the next day.

Irene was discharged in stable cardiac condition and was instructed to follow up in

two weeks with the cardiologist. Irene was never screened for a possible pulmonary

embolism.

      Three days after she went home, Irene was found lying in bed and struggling to

breathe. Once again returning to the Hospital by ambulance, Irene arrived pale,

unresponsive, and in severe respiratory distress. Despite intubation and resuscitation

efforts, Irene died the same day. An autopsy showed that Irene had “massive bilateral

      2
        The facts recited accord with those alleged in the petition and in the expert
report. See Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 221 n.1 (Tex. 2018). We
use initials and aliases for the plaintiff’s side because Irene’s minor children are
involved in this case.

                                           3
pulmonary thromboemboli.”3 The cause of death was ruled as pulmonary

thromboemboli as well as atherosclerotic coronary-artery disease.

      Irene’s husband, J.B. (“Joseph”), individually and as Irene’s estate

representative and on behalf of the couple’s two minor children, sued three treating

physicians and their respective practice groups, as well as the Hospital—Medical City

Arlington and HCA4—for negligence.

      Joseph timely served the Hospital with an expert report prepared by Dr. Cam

Patterson, a cardiologist, along with Dr. Patterson’s curriculum vitae. 5 See id.

§ 74.351(a). Among other things, Dr. Patterson opined that hospitals must have

policies, procedures, and guidelines in place to “ensure that patients presenting with

chest pain, shortness of breath[,] and severe syncope are properly evaluated, assessed,

      3
        “Massive pulmonary embolism is defined as obstruction of the pulmonary
arterial tree that exceeds 50% of the cross-sectional area, causing acute and severe
cardiopulmonary failure from right ventricular overload.” Alireza Sadeghi et al, Case
Report, Acute Massive Pulmonary Embolism: Role of the Cardiac Surgeon, 32 Tex. Heart Inst.
J. 430, 430 (2005), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1336727/
pdf/20050900s00039p430.pdf (last visited Nov. 1, 2021).
      4
        Although the petition does not say so, HCA and Medical City Arlington
appear to be related entities. Joseph lodged identical allegations against both of them,
and HCA joined in Medical City’s objections to Joseph’s Chapter 74 reports and
motion to dismiss. But in that joinder, HCA did “not concede that it owned or
operated Medical City Arlington, employed, controlled[,] or otherwise held out any
health care provider as its agent, nor that HCA Inc. provided care to” Irene. The
exact relationship between the two appellees is irrelevant to our analysis.
      5
        Joseph served two other expert reports, but Dr. Patterson’s was the only one
that related to the Hospital.

                                            4
tested, treated[,] and diagnosed” and must also have “appropriate clinical pathways to

ensure appropriate testing is conducted to rule out medical emergencies, such as

pulmonary embolism.” Dr. Patterson described what he called a necessary “triple rule

out” protocol (as part of safety-based Joint Commission accrediting standards) to

“exclude acute coronary syndrome, pulmonary embolus[,] and aortic dissection” for

patients like Irene who present with cardiac abnormalities. Dr. Patterson described the

“triple rule out” protocol as requiring “either a series of test[s] or specific protocol to

perform imaging studies to include or exclude pulmonary embolism as a diagnosis,

such as a protocol for performing CT angiogram, which is a triple rule out study.” Dr.

Patterson additionally opined that Medical City Arlington violated the standard of care

by “[a]llowing a patient with [Irene’s] clinical presentation and biomarkers to be

treated and discharged with unexplained etiology [that is, an unexplained cause],

without appropriate directives for close follow-up,” and by failing to “have and/or

enforce proper guidelines, protocols[,] and procedures to prevent a patient with this

symptomology from being routinely discharged with unexplained etiology, without

appropriate directives for close follow-up.” The report did not mention HCA.

      The Hospital objected to Dr. Patterson’s expert report and moved to dismiss

Joseph’s claims. See id. § 74.351(b). Following a hearing, the trial court overruled the

Hospital’s objections and denied its motion to dismiss. The Hospital then perfected

this interlocutory appeal. See id. § 51.014(a)(9) (allowing appeal from order denying

Section 74.351(b) motion).

                                            5
                                       II. Analysis

       A.     TMLA expert reports, generally

       The TMLA requires healthcare-liability claimants to serve an expert report on

each defendant not later than 120 days after that defendant files an answer. Abshire,

563 S.W.3d at 223 (citing Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a)). This

requirement functions “to weed out frivolous malpractice claims in the early stages of

litigation, not to dispose of potentially meritorious claims.” Id.

       An expert report must fairly summarize the expert’s opinions regarding

applicable standards of care, how the care provided failed to meet the standards, and

the causal relationship between that failure and the injury, harm, or damages claimed.

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6). To opine about whether a non-

physician healthcare provider such as the Hospital departed from accepted standards

of care, the expert must be “qualified to testify under the requirements of Section

74.402.” Id. § 74.351(r)(5)(B). Section 74.402 in turn provides that a person may

qualify as an expert on the healthcare provider’s departure from standards of care only

if the person knows about accepted standards of care for the healthcare provider’s

diagnosis, care, or treatment of the condition involved and is qualified on the basis of

training or experience to offer an expert opinion about those care standards. Id.

§ 74.402(b)(2), (3).

       In deciding whether an expert is qualified based on training or experience, the

trial court considers whether the witness

                                             6
        (1) is certified by a licensing agency of one or more states of the United
        States or a national professional certifying agency, or has other
        substantial training or experience, in the area of health care relevant to
        the claim; and

        (2) is actively practicing health care in rendering health care services
        relevant to the claim.

Id. § 74.402(c).

        The expert’s qualifications cannot be inferred but must appear in the report or

in the expert’s CV. See Jacksboro Nursing Operations, LLC v. Norman, No. 02-20-00262-

CV, 2021 WL 1421431, at *4 (Tex. App.—Fort Worth Apr. 15, 2021, no pet.) (mem.

op.);   Savaseniorcare   Admin.   Servs.,   L.L.C.   v.   Cantu,   No.   04-14-00329-CV,

2014 WL 5352093, at *2 (Tex. App.—San Antonio Oct. 22, 2014, no pet.) (mem. op.).

        Concerning the standard of care and how to adequately identify it, the report

“must set forth ‘specific information about what the defendant should have done

differently.’” Abshire, 563 S.W.3d at 226 (quoting Am. Transitional Care Ctrs. of Tex. v.

Palacios, 46 S.W.3d 873, 880 (Tex. 2001)). “While the [TMLA] requires only a ‘fair

summary’ of the standard of care and how it was breached, ‘even a fair summary must

set out what care was expected, but not given.’” Id. (quoting Palacios, 46 S.W.3d at

880).

        Regarding causation, the report must “explain ‘how and why’ the alleged

negligence caused the injury in question.” Id. at 224. Conclusory descriptions of

causation are not adequate; “the expert must explain the basis of his statements and

link conclusions to specific facts.” Id. But “[i]n satisfying th[e] ‘how and why’

                                              7
requirement, the expert need not prove the entire case or account for every known

fact; the report is sufficient if it makes ‘a good-faith effort to explain, factually, how

proximate cause is going to be prove[d].’” Id. (quoting Columbia Valley Healthcare Sys.,

L.P. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017)). Further, “[t]he sufficiency of the

expert report’s causation statement should be viewed in the context of the entire

report.” Columbia Med. Ctr. of Arlington Subsidiary L.P. v. L.M., No. 02-17-00147-CV,

2018 WL 1095746, at *7 (Tex. App.—Fort Worth Mar. 1, 2018, no pet.) (mem. op.).

Finally, “the detail needed to establish a causal link generally is proportional to the

complexity of the negligent act giving rise to the claim.” Id. In other words, a

“causation opinion is not conclusory simply because it is not complex.” Id.

      A motion to dismiss based on the inadequacy of a Chapter 74 report can be

granted only “if it appears to the court, after hearing, that the report does not

represent an objective good[-]faith effort to comply” with the statute’s definition of

an “expert report.” Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l), (r)(6). The Texas

Supreme Court has held that a good-faith effort involves “(1) informing the defendant

of the specific conduct called into question and (2) providing a basis for the trial court

to conclude the claims have merit.” Abshire, 563 S.W.3d at 223 (quoting Baty v. Futrell,

543 S.W.3d 689, 693–94 (Tex. 2018)). “‘[A] report that merely states the expert’s

conclusions about the standard of care, breach, and causation’ is insufficient.” Id.

(quoting Palacios, 46 S.W.3d at 877). A report need not meet the standards of

summary-judgment evidence. Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d

                                            8
510, 517 (Tex. 2017) (“We remain mindful that an ‘adequate’ expert report ‘does not

have to meet the same requirements as the evidence offered in a summary-judgment

proceeding or at trial.’” (quoting Scoresby v. Santillan, 346 S.W.3d 546, 556 n.60 (Tex.

2011))).

      We apply an abuse-of-discretion standard in evaluating the trial court’s decision

to grant or deny a motion to dismiss challenging an expert report’s adequacy. Abshire,

563 S.W.3d at 223. Our review is limited to the information contained within the four

corners of the report. Id. We defer to the trial court’s factual determinations if the

evidence supports them but review its legal conclusions de novo. See Columbia N. Hills

Hosp. Subsidiary, L.P. v. Gonzales, No. 02-16-00433-CV, 2017 WL 2375770, at *4 (Tex.

App.—Fort Worth June 1, 2017, no pet.) (mem. op.). Although an abuse occurs if the

trial court rules without reference to guiding rules or principles or renders a decision

lacking support in the case’s facts or circumstances, an abuse does not occur just

because a trial court decides a matter differently than we might have. Id.

      B.     Dr. Patterson’s qualifications6

      Dr. Patterson’s report states that he is a licensed physician “currently in the

active practice of Adult Cardiology”; is board-certified in the field of cardiovascular

medicine; is chancellor and a professor of medicine at the University of Arkansas

      6
       Dr. Patterson’s report includes his qualifications to opine about the care
provided by Irene’s cardiologist, who was not a Hospital employee; we focus here
only on the report’s and CV’s contents as they relate to Dr. Patterson’s qualifications
to opine about the Hospital and its alleged direct liability for Irene’s death.

                                           9
School for Medical Sciences in Little Rock; has over twenty years’ experience of

clinical practice and teaching at various medical schools as a professor of cardiology;

has “significant experience in both clinical practice and hospital administration” that

makes him “qualified to render an opinion as to the standard of care for” the

Hospital; has been physician-in-chief of the University of North Carolina Center for

Heart and Vascular Care, executive director of UNC McAllister Heart Institution, and

chief of the cardiology division at UNC Chapel Hill; and has “an extensive

background in the development, implementation[,] and enforcement of safe,

appropriate[,] and efficacious cardiovascular care pathways as well as guideline and

policy development for optimal interventional clinical care for hospital cardiovascular

treatment.”7 Dr. Patterson’s CV reflects that he also spent four years as senior vice

president and chief operating officer at Weill-Cornell Medical Center and Komansky

Children’s Hospital/New York Presbyterian Hospital.

      7
       The entirety of this portion of the report states:

      Furthermore, with significant experience in both clinical practice and
      hospital administration, I am also qualified to render an opinion as to the
      standard of care for Medical City Arlington. As physician-in-chief of the
      UNC Center for Heart and Vascular Care, Executive Director of UNC
      McAllister Heart Institute and Chief of the Division of Cardiology at the
      University of North Carolina at Chapel Hill, as well as Chancellor and
      Professor of Medicine at the University of Arkansas for Medical
      Sciences, I have an extensive background in the development,
      implementation[,] and enforcement of safe, appropriate[,] and efficacious
      cardiovascular care pathways as well as guideline and policy development
      for optimal interventional clinical care for hospital cardiovascular
      treatment.

                                           10
       The Hospital argues that this background does not establish Dr. Patterson’s

qualifications to offer an opinion either about the standard of care applicable to the

Hospital (including what its policies and procedures should be concerning a “triple

rule out” protocol) or about causation. Based on our precedents, we must agree.

       Before explaining those precedents, we first note that our sister court in Dallas

recently reached the opposite conclusion about Dr. Patterson’s qualifications.8 Decker

v.   Columbia   Med.    Ctr.   of   Plano,   Subsidiary,   L.P.,   No.   05-19-01508-CV,

2020 WL 6073880 (Tex. App.—Dallas Oct. 15, 2020, pet. denied) (mem. op.). In

Decker, the trial court had held that Dr. Patterson was not qualified to opine about the

standard of care for a hospital.9 Id. at *1. But the Dallas court reversed:

                Patterson’s report and curriculum vitae demonstrate he is
       qualified to opine about the standard of care applicable to [Columbia
       Medical Center of Plano dba Medical City Plano and HCA]. He is
       licensed to practice medicine in several states, board certified in
       cardiovascular medicine, actively engaged in the practice
       of . . . cardiology, and is a Professor of Cardiology. See Tex. Civ. Prac. &
       Rem. Code § 74.402(c). Additionally, he has experience in hospital

       “[W]hile we respect our sister courts’ decisions, we are not bound by their
       8

precedent.” P.C. ex rel. C.C. v. E.C., 594 S.W.3d 459, 464 (Tex. App.—Fort Worth
2019, no pet.).
       9
        Although the Dallas court did not detail Dr. Patterson’s opinions about the
ways in which that hospital had allegedly failed to satisfy the standard of care, Joseph’s
post-submission letter brief bringing Decker to our attention stated that Dr. Patterson
had described the same failure to have the “triple rule out” protocol in place and had
described his qualifications exactly as he did here. The Hospital’s response to Joseph’s
letter brief did not take issue with either of those representations, and because the
same law firms represented the opposing parties in Decker as in this case, we assume
that Joseph has correctly characterized Dr. Patterson’s Decker report.

                                             11
       administration, and his background includes “the development,
       implementation and enforcement of safe, appropriate and efficacious
       cardiovascular care pathways as well as guidelines and policy
       development for optimal interventional clinical care for hospital
       cardiovascular treatment.”

Id. at *3 (concluding that Patterson’s training and experience qualified him to opine

about “a hospital’s policies and procedures with respect to the treatment of cardiology

patients”).

       Despite the Dallas court’s holding, our own precedents and a close look at the

wording of Dr. Patterson’s report compel us to conclude that although he certainly

knows how to treat cardiology patients as a clinician, his report and CV do not show

that he has the requisite familiarity with or experience in developing, implementing,

and enforcing hospital policies and procedures.

       For example, in a direct-liability claim involving a patient who died from

complications after a hysterectomy, we analyzed a board-certified OB-GYN’s

qualifications to opine on a hospital’s standard of care for its post-surgery recovery-

room nurses. See Columbia N. Hills Hosp. Subsidiary, L.P. v. Alvarez, No. 02-10-00342-

CV, 2011 WL 3211239 (Tex. App.—Fort Worth July 28, 2011, no pet.) (mem. op. on

reh’g). Although the expert was qualified when it came to how nurses should treat

post-op patients, 10 the same could not be said for his opinions about the hospital

        The physician was familiar with the standard of care for treating patients like
       10

the deceased, had cared for hundreds of similar patients, and was “familiar with the
standards of care for recovery room and post-operative nurses caring for patients like
Mrs. Alvarez through his experience working with those nurses.” Alvarez,

                                          12
itself. The report “d[id] not establish” that the expert had “any familiarity, training, or

experience that would allow him to opine as to the standard of care for a hospital in

formulating training programs, formulating or enforcing its policies and procedures,

or supervising its nurses,” id. at *5 (citing Hendrick Med. Ctr. v. Conger, 298 S.W.3d 784,

788 (Tex. App.—Eastland 2009, no pet.))—those were matters involving an “entirely

separate” standard of care from that applicable to recovery-room nursing care, id.

(citing Denton Reg’l Med. Ctr. v. LaCroix, 947 S.W.2d 941, 950–51 (Tex. App.—Fort

Worth 1997, pet. denied)). We wrote:

      Although Dr. Tyuluman’s report states that he has served as chairman of
      a hospital quality improvement committee and a member of a clinical
      case review committee, nowhere in the report does he state that as a
      result of this or other experience he is familiar with the standard of care
      for a reasonable, prudent hospital in training its nurses, in enforcing its
      policies and procedures, and in supervising its nurses. The report does
      not indicate that, as a result of his committee service, Dr. Tyuluman
      gained experience in formulating, implementing, or monitoring either
      hospital nurses’ training or enforcement of hospital policies and
      procedures or hospital nurses’ supervision.

Id.

      The same was true in another of our cases, Texas Health Harris Methodist Hospital

Fort Worth v. Biggers, Nos. 02-12-00486-CV, 02-13-00040-CV, 2013 WL 5517887 (Tex.

App.—Fort Worth Oct. 3, 2013, no pet.) (mem. op.). Biggers arose out of an

2011 WL 3211239, at *4. We thus affirmed that vicarious-liability claims against the
hospital that employed the nurses could proceed. Id. Here, in contrast, Joseph has not
alleged that the Hospital’s nursing staff was negligent, nor has he raised any other type
of vicarious-liability claim.

                                            13
emergency craniectomy in which part of the patient’s skull was temporarily removed

to relieve pressure and allow for brain surgery following a car crash, but because the

removed portion was improperly stored and thus could not be reattached, the patient

ended up with artificial implants that led to repeated infections and additional

surgeries. Id. at *1. Among other defendants, the plaintiffs sued Harris Methodist

Hospital and Community Tissue Services—a “bone bank,” or “tissue bank,” that

preserves such things as bone material for later use, id. at *5—and provided a Chapter

74 report from an orthopedic surgeon. Id. at *1.

       We sustained Harris Methodist’s and Community’s challenges to the expert’s

qualifications. As to the hospital, although the expert had extensive surgical

experience involving bone and tissue grafts, he did not state whether he had “worked

or interacted with hospital staff to preserve and store tissue or that he ha[d] any

knowledge of hospital procedures beyond a cursory statement that he [was] ‘fully

familiar with standards of care that involve preservation of tissue and storing of tissue

by . . . hospitals.’” Id. at *4. The report contained “nothing . . . from which a trial

court could conclude that he is familiar with the standards of care for hospitals.” Id.

Similarly, nothing indicated that the expert was familiar with the standard of care for a

tissue bank like Community. Id. He did not state that he had “any knowledge or

experience with the cleaning or storage procedures of tissue banks and whether they

differ from those of a hospital or with the transfer procedures from the hospital to

the tissue bank.” Id.

                                           14
       And although it involved a summary judgment rather than a Chapter

74 challenge, yet another of our cases informs how we analyze Dr. Patterson’s

qualifications here: Reed v. Granbury Hospital Corp., 117 S.W.3d 404 (Tex. App.—Fort

Worth 2003, no pet.). There, a hospital was sued for failing to have protocols for

administering tPA 11 to stroke patients, and in support of the plaintiffs’ claims, an ER

doctor and a neurologist each submitted an affidavit and was deposed concerning the

hospital’s alleged administrative negligence for that failure. Id. at 410–12.

       Affirming summary judgment for the hospital after the trial court struck the

doctors’ standard-of-care testimony, we first held that although the ER doctor might

have been qualified to opine about the standard of care applicable to a physician’s

decision about whether to administer tPA, the record did not show that the doctor

“possessed any special knowledge about what protocols, policies, or procedures a

hospital of ordinary prudence, with the Hospital’s capabilities, would have had in

place.” Id. at 411. We next discussed the neurologist and held that he, too, was not

qualified to opine about hospitals’ tPA protocols. Id. at 411–12. Even though the

neurologist had treated hundreds of stroke patients, had administered tPA to many of

them, and had “participated in the creation of a hospital protocol in stroke

        Tissue plasminogen activator, or tPA, breaks up blood clots and can improve
       11

patient outcomes if administered within three hours of stroke symptoms’ onset. Reed,
117 S.W.3d at 407 & n.1.

                                            15
pathways”12 that he described as an area similar to tPA therapy, he was unfamiliar

“with hospital protocols for the administration of tPA to stroke patients, with the

possible exception of the hospitals in which he practiced.” Id.

      Dr. Patterson’s report suffers from the same deficiencies we found in Alvarez,

Biggers, and Reed. Although he writes that he has “an extensive background in the

development, implementation[,] and enforcement of safe, appropriate[,] and

efficacious cardiovascular care pathways as well as guideline and policy development

for optimal interventional clinical care for hospital cardiovascular treatment,” Dr.

Patterson does not describe or connect the dots between clinical pathways he has

developed and the “triple rule out” protocol for which he advocates in this case—or

even whether his work has been in the context of developing administrative, hospital-

specific policies and procedures. Nor does his report detail his claimed “significant

experience” in “hospital administration,” much less in a way that qualifies him to

      12
         In the medical profession, a clinical pathway—whether for evaluating and
treating strokes, heart attacks, stomachaches, or anything else—is

      a multidisciplinary management tool based on evidence-based practice
      for a specific group of patients with a predictable clinical course, in
      which the different tasks (interventions) by the professionals involved in
      the patient care are defined, optimized[,] and sequenced either by hour
      (ED), day (acute care)[,] or visit (homecare). Outcomes are tied to
      specific interventions.

See Clinical pathway, Wikipedia, https://en.wikipedia.org/wiki/Clinical_pathway (last
visited Nov. 1, 2021). A particular clinical pathway “tries to capture the foreseeable
actions which will most commonly represent best practice for most patients most of
the time.” Id.

                                           16
opine on the standard of care for the Hospital; his duties as physician-in-chief of

UNC’s Center for Heart and Vascular Care, as executive director of UNC’s McAllister

Heart Institution, as chief of the cardiology division at UNC Chapel Hill, and as

senior VP and COO at Weill-Cornell Medical Center and Komansky Children’s

Hospital/New York Presbyterian Hospital are not explained in his report or CV.

      Bound as we are to discern Dr. Patterson’s qualifications only from within the

four corners of his report and CV, e.g., Jacksboro Nursing, 2021 WL 1421431, at *4, we

cannot find or infer from either document any familiarity with hospital-specific

administrative standards of care that would qualify him to opine about proper testing

and diagnosis, about the “triple rule out” protocol, or about discharge policies.

Indeed, although his report states—quite accurately, it seems—that he is “familiar

with the evaluation and treatment of cardiac patients with clinical presentations similar

to” Irene, he does not state that he is similarly familiar with how hospitals develop and

put into place (or should put into place) the policies and procedures he outlines.13 See

Alvarez, 2011 WL 3211239, at *5 (holding that report was deficient where physician

did not state that as a result of his service as chair of hospital quality-improvement

committee and as member of clinical case-review committee he had become “familiar

      13
         Joseph’s brief recites that “Dr. Patterson states that he is familiar with not
only his practice area (cardiology) but also hospital protocols for the evaluation and
treatment of cardiac patients who present at a hospital with clinical symptoms similar
to [Irene].” But the report does not say that, and the record citation for this statement
is to a page number outside the range of the clerk’s record’s 424 pages.

                                           17
with the standard of care for a reasonable, prudent hospital in training its nurses, in

enforcing its policies and procedures, and in supervising its nurses” or that his

committee service had produced “experience in formulating, implementing, or

monitoring either hospital nurses’ training or enforcement of hospital policies and

procedures or hospital nurses’ supervision”); cf. Biggers, 2013 WL 5517887, at

*4 (holding that “cursory statement” that physician was “‘fully familiar with standards

of care that involve preservation of tissue and storing of tissue by . . . hospitals’” was

not enough to establish his qualifications to opine about those standards).

      We conclude that Dr. Patterson’s report and CV fail to establish his

qualifications to opine about standards of care relating to the Hospital’s policies and

procedures (or lack thereof) concerning a patient such as Irene. And from this

conclusion, it flows logically that Dr. Patterson has similarly failed to establish his

qualifications to opine about causation. See Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(r)(5)(C), (r)(6) (in connection with causation, defining “expert report” as one

prepared by an expert qualified under the Texas Rules of Evidence to opine about the

causal relationship between injury and departure from applicable standard of care and

fairly summarizing expert’s opinion about the “causal relationship between that failure

and the injury, harm, or damages claimed”); cf., e.g., Whisenant v. Arnett, 339 S.W.3d

920, 927 (Tex. App.—Dallas 2011, no pet.) (holding that if physician is qualified to

offer expert opinion on standard of care, trial court can reasonably conclude that

expert is also qualified to opine on causation). We do agree with Joseph that Dr.

                                           18
Patterson is qualified to opine that the cause of his wife’s death was untreated

pulmonary embolism. But beyond that, Dr. Patterson does not explain how he is

qualified to opine that the Hospital’s alleged breach of some administrative policy-

and-procedure standards of care proximately caused Irene’s death.

       We sustain the Hospital’s first issue.

       C.     Conclusory nature of Dr. Patterson’s opinions

       The Hospital alternatively argues that the opinions in Dr. Patterson’s report

concerning the standards of care, their breach, and causation are all conclusory, and

thus the report is deficient under the TMLA. 14 We agree.

       Joseph’s direct-liability claims—that the Hospital allegedly violated the

standards of care (1) by failing to have a “triple rule out” protocol, or policies and

procedures to ensure that a patient like Irene is properly evaluated, diagnosed, and

treated, and (2) by allowing a patient like Irene to be discharged—all implicate the

practice of medicine. But “[a] hospital cannot practice medicine and therefore cannot

       14
         The Hospital’s second issue includes an assertion that Dr. Patterson’s
conclusory opinions “do not constitute an objective good[-]faith effort to comply
with the section 74.351 requirements,” which if true would authorize us to render
judgment in the Hospital’s favor. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l)
(stating that court must grant motion challenging adequacy of expert report “only if it
appears to the court, after hearing, that the report does not represent an objective
good[-]faith effort to comply with the definition of an expert report”); see, e.g., Patel v.
Harmon, 213 S.W.3d 449, 451–52 (Tex. App.—Eastland 2006, no pet.) (holding that
expert report did not constitute good-faith effort and rendering judgment dismissing
plaintiff’s claims). The Hospital has asked us only to reverse and remand and does not
seek a judgment from us dismissing Joseph’s claims for want of a good-faith effort.

                                            19
be held directly liable for any acts or omissions that constitute medical functions.”

Reed, 117 S.W.3d at 415. If such things as establishing administrative polices on

ordering particular tests and discharging patients aren’t medical functions, an expert

purporting to pin direct rather than vicarious blame on a hospital for a policy or

protocol failure should reasonably be expected to explain how his opinions do not

implicate the practice of medicine, even at this preliminary stage.

       As the Hospital points out, diagnosing and treating illness is the practice of

medicine, which is solely a physician function. See, e.g., Zamarripa, 526 S.W.3d at

461 n.36 (noting that Texas law prohibits nurses from practicing medicine, which is

statutorily defined as “the diagnosis, treatment, or offer to treat a mental or physical

disease or disorder . . . or injury . . .” (quoting Tex. Occ. Code Ann. § 151.002(a)(13)));

Drs. Hosp. at Renaissance, Ltd. v. Andrade, 493 S.W.3d 545, 548 (Tex. 2016) (explaining

that although hospital is institution licensed to provide healthcare, only licensed

physician can give medical care); Sanchez v. Martin, 378 S.W.3d 581, 596 (Tex. App.—

Dallas 2012, no pet.) (explaining that hospitals have no duty to disclose medical or

surgical risks or to obtain informed consent to surgery because that is a “nondelegable

duty imposed solely upon the treating doctor”) (quoting Espalin v. Child.’s Med. Ctr.,

27 S.W.3d 675, 686 (Tex. App.—Dallas 2000, no pet.)); see also Tex. Occ. Code Ann.

§§ 155.001–.003 (establishing that only a “person” can be licensed to practice

medicine).

                                            20
       Zamarripa involved a pregnant patient who died while being transferred to a

second hospital at her treating physician’s directive. 526 S.W.3d at 456–57. The

deceased’s minor children’s guardian sued Valley Regional (the original hospital) and

others. The plaintiff claimed that Valley Regional’s nurses negligently allowed the

patient to be discharged when she was not suitable for discharge and that hospital

personnel negligently allowed a ground ambulance transfer when the patient should

not have been transferred. Id. at 457. In addition to providing a nurse’s expert report

on nursing standards of care, Zamarripa provided a physician’s expert report on

causation15—that is, on foreseeability and cause-in-fact. Id. at 460. But the supreme

court held that the physician’s report was deficient:

       [Dr.] Harlass . . . stated only that by “permitting and facilitating the
       transfer,” Valley Regional caused Flores to be in an ambulance when she
       suffered a placental abruption and cardiac arrest, leading to her death.
       But as Harlass himself explains, it was Dr. Ellis [Flores’s treating
       physician] who ordered Flores’s transfer, not Valley Regional. Harlass
       does not explain how Valley Regional permitted or facilitated Flores’s
       transfer, or even whether Valley Regional had any say in the
       matter. . . . Neither [the nurse expert] nor Harlass explains how Valley
       Regional had either the right or the means to persuade Dr. Ellis not to
       order the transfer or to stop it when he did.

              Zamarripa’s response is that the Act does not require such
       explanations in expert reports. But without factual explanations, the
       reports are nothing more than the ipse dixit of the experts, which we have
       held are clearly insufficient.

Id. at 461.

        A causation expert must be a physician. See Tex. Civ. Prac. & Rem. Code
       15

Ann. § 74.351(r)(5)(C).

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      In addition, as we know from Palacios, “[w]hether a defendant breached his or

her duty to a patient cannot be determined absent specific information about what the

defendant should have done differently.” 46 S.W.3d at 880. Dr. Patterson’s report

does not identify who at the Hospital could have overridden or second-guessed the

medical decisions of Irene’s treating physicians, or how any Hospital employee or

administrator could have done so without improperly engaging in the corporate

practice of medicine. And even though hospitals can and do implement a variety of

policies and procedures without “practicing medicine,” Dr. Patterson’s opinions as

written describe things that only physicians can do: ordering tests, making diagnoses,

discharging patients, and the like. The report is thus conclusory about the standards of

care applicable to the Hospital and the breach of those standards.

      The report is also conclusory on proximate cause. Dr. Patterson opined that

the “multiple failures” by Irene’s cardiologist and the Hospital “made it highly

foreseeable that significant injury or death could result.” He then stated that the

“severity of this collective diagnostic miss evidences failures by an unsafe system,

unsafe practice environment[,] and unsafe clinicians proceeding with high risk, and

therefore, unsafe care.” Dr. Patterson described it as “imperative” for the treating

physician to “take the appropriate steps, and for [the Hospital] to have procedures in

place, to ensure pulmonary embolism was ruled out as a potential underlying

etiology,” but this “life-threatening condition was not appropriately assessed,

                                          22
monitored, diagnosed[,] and treated, which greatly increased the risk of a fatal

thromboemboli event, which ultimately occurred.”

       Joseph maintains that Dr. Patterson’s report satisfies Abshire by “drawing a

line” directly from the Hospital’s failure to implement the “triple rule out” protocol,

to the failure to diagnose the pulmonary embolism, to Irene’s ultimately injury. See

563 S.W.3d at 226 (holding that expert report satisfied causation requirement by

directly linking nurses’ failure to properly document patient’s medical history to

patient’s delayed treatment and subsequent injury). It’s true that Abshire held that an

expert “need not prove the entire case or account for every known fact” and that a

report is sufficient if it makes a good-faith effort to explain, factually, how proximate

cause will be proved. Id. at 224. Still, though, as the Hospital points out, Abshire also

reiterated that an expert must explain “how and why” the alleged negligence caused

the injury in question. Id. Dr. Patterson does not explain how and why Hospital

policies, procedures, and protocols—which can be implemented only through its

nurses and staff—could have changed what the physician did in ordering tests, making

his diagnosis, and discharging Irene when she was in stable cardiac condition. See

Zamarripa, 526 S.W.3d at 461 (holding that expert’s failure to explain how hospital

could have countermanded doctor’s transfer orders rendered report nothing more

than insufficient ipse dixit).

       We sustain the Hospital’s second issue.

                                           23
                                 III.   Conclusion

      Having sustained Medical City Arlington’s and HCA’s first two issues, we

reverse the trial court’s order overruling their objections to the expert report of Dr.

Cam Patterson and denying their motion to dismiss, and we remand the case to the

trial court so that it can consider whether to grant a 30-day extension to cure the

report’s deficiencies. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(c).

                                                     /s/ Elizabeth Kerr
                                                     Elizabeth Kerr
                                                     Justice

Delivered: November 4, 2021

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