Court Opinion

ID: 9913647
Source: CourtListenerOpinion
Date Created: 2023-12-28 16:13:20.673284+00
Date Added: 2024-06-11T13:08:33.137667
License: Public Domain

COURT OF APPEALS OF VIRGINIA

              Present: Judges Chaney, Callins and White
UNPUBLISHED

              Argued at Alexandria, Virginia

              JEFFREY M. COLLINS
                                                                              MEMORANDUM OPINION* BY
              v.      Record No. 1756-22-4                                   JUDGE DOMINIQUE A. CALLINS
                                                                                 DECEMBER 28, 2023
              MARTIN A. KORKOWSKI, M.D., ET AL.

                                    FROM THE CIRCUIT COURT OF LOUDOUN COUNTY
                                               Stephen E. Sincavage, Judge

                               Thomas M. Wochok; William E. Artz (William E. Artz, P.C., on
                               briefs), for appellant.

                               Michael E. Olszewski (Tracie M. Dorfman; Nicholas J.N. Stamatis;
                               Hancock, Daniel & Johnson, P.C., on brief), for appellees.

                      After being diagnosed with Stage 4 prostate cancer, Jeffrey Collins sued Dr. Martin

              Korkowski and Dr. Korkowski’s employer, Loudoun Medical Group (“Dr. Korkowski”

              collectively), for medical malpractice. Collins claimed that Dr. Korkowski breached the standard of

              care by failing to refer him to a urologist after his blood tests suggested he had prostate cancer,

              thereby delaying the diagnosis and treatment of his cancer. Collins maintained that, because

              Dr. Korkowski did not refer him to a urologist, his cancer progressed to the point that it became

              incurable and terminal. Collins appeals several evidentiary rulings by the trial court. He asserts that

              the trial court erred by excluding his proposed rebuttal expert testimony, by admitting excerpts of

              his deposition during Dr. Korkowski’s defense and then excluding his own “cross-designation” of

              deposition testimony, and by allowing Dr. Korkowski to question a defense expert on redirect

                      *
                          This opinion is not designated for publication. See Code § 17.1-413(A).
without allowing further cross-examination from Collins. Finally, he maintains that these errors,

separately or in combination, violated his due process rights and his constitutional right to a fair

trial. For the following reasons, we affirm the trial court’s judgment.

                                          BACKGROUND1

                                    I. Collins’s Medical Timeline

        On April 5, 2000, Collins saw Dr. Korkowski, an internal medicine physician, for an

annual physical, including a prostate examination. Although Dr. Korkowski found no

abnormalities during the prostate examination, he ordered a prostate-specific antigen (“PSA”)

blood test to screen for prostate cancer. The PSA results on April 7, 2000, were within normal

ranges. When Collins repeated the PSA test in 2003, the results remained within normal ranges.

        Collins did not see Dr. Korkowski again until 2007, when he complained of left breast

pain. Further tests revealed that Collins’s testosterone levels were 178 ng/dL, which was below

the normal range of 241-827 ng/dL. Collins did not have a PSA test at that time. When Collins

next saw Dr. Korkowski on October 28, 2016, his rectal exam revealed he had an enlarged

prostate. Dr. Korkowski prescribed Flomax and ordered a PSA test. The test results revealed

that Collins’s PSA level at 9.11 ng/mL was elevated and exceeded the normal range of 0-4

ng/mL. Based on Collins’s symptoms and the absence of nodules during the rectal exam,

Dr. Korkowski believed that Collins likely had benign prostatic hypertrophy (BPH) and

informed him he had an “enlarged prostate.” Dr. Korkowski nevertheless recommended a repeat

PSA test in four to six months.

        Collins saw Dr. Korkowski again in August 2017. At that time, Collins’s PSA was

8.49 ng/mL—lower than it had been in October 2016, but still elevated. On August 25, 2017,

        1
         “In reviewing the evidence presented at trial, we view it ‘in the light most favorable to
the prevailing party, granting it the benefit of any reasonable inferences.’” Pergolizzi v.
Bowman, 76 Va. App. 310, 317 n.1 (2022) (quoting Starr v. Starr, 70 Va. App. 486, 488 (2019)).
                                                  -2-
Dr. Korkowski noted that Collins’s PSA levels were “[h]eaded in [the] right direction.” When

Collins tested his PSA again in January 2018, it had risen to 10.86 ng/mL. Dr. Korkowski

prescribed antibiotics and noted that Collins had a history of “BPH.” On February 26, 2018,

Dr. Korkowski continued Collins on antibiotics and recommended that he recheck his PSA the

following month.

       Several weeks later, on May 7, 2018, Collins saw Dr. Korkowski and complained of

having intermittent groin pain for two months. A rectal exam revealed that Collins’s prostate

was enlarged, but Dr. Korkowski felt no nodules or abnormal “tone.” Dr. Korkowski ordered

another PSA test. The May 8, 2018 results reflected that Collins’s PSA levels had risen to 14.52

ng/mL. On June 20, 2018, Collins called Dr. Korkowski’s office for the results. Dr. Korkowski

reviewed the results with Collins and referred him to a urologist.

       On July 5, 2018, urologist Dr. Kevin O’Connor examined Collins and found that his

prostate was enlarged “with a firm area in the left gland.” A subsequent biopsy revealed cancer

in several sites. The “Gleason” score for each sample, reflecting the cancer grade, ranged from 7

through 9. On October 15, 2018, Collins underwent a prostatectomy. Based on the pathology

studies from the surgery, Collins was diagnosed with a high-grade adenocarcinoma2 that had

spread to four of ten lymph nodes. Collins sought treatment with an oncologist, who diagnosed

him with Stage 4 cancer.

                                     II. The Incidents of Trial

                A. Plaintiff’s Evidence

       At trial, Collins presented expert testimony from three physicians: Dr. Robert Perkel, a

family practice doctor; Dr. Mohummad Siddiqui, a urologic oncologist; and Dr. Jiaoti Huang, a

pathologist specializing in neuroendocrine prostate cancer. Dr. Perkel opined that

       2
           The pathology studies concluded that Collins’s Gleason score was 9 out of 10.
                                                -3-
Dr. Korkowski breached the standard of care by failing to inform Collins that his elevated PSA

results in 2016 could reflect prostate cancer and by failing to recommend a repeat PSA test

within four to twelve weeks.3 Dr. Perkel also opined that Dr. Korkowski breached the standard

of care by failing to refer Collins to a urologist after his PSA results remained elevated in May

2017 and by again failing to refer him to a urologist when his PSA results rose further in January

2018.

        Dr. Siddiqui concurred, opining that Dr. Korkowski breached the standard of care by

either failing to refer Collins to a urologist after his October 28, 2016 PSA test or by retesting

him “in a much shorter time period” than four to six months. Dr. Siddiqui testified that, when

Collins’s PSA results in August 2017 remained elevated, Dr. Korkowski breached the standard

of care by failing to refer Collins to a urologist. Moreover, Dr. Siddiqui opined that, if Collins’s

cancer had been diagnosed in 2016 or 2017, there was a 90 to 95% likelihood that a

prostatectomy would have cured him; but, because the cancer had metastasized, Collins’s

five-year survival rate was less than 10%. Dr. Siddiqui stressed that, based on Collins’s rectal

exam and PSA levels during that time frame, the cancer had likely not yet spread past the

prostate capsule. Dr. Siddiqui did not believe that Collins had high-grade metastatic prostate

cancer before October 2016; however, he noted that patients with high-grade prostate cancer

could be cured if the cancer is detected early.

        Dr. Huang testified to causation only and did not address whether Dr. Korkowski

breached the standard of care. He testified that Collins had prostate cancer as early as October

28, 2016, but, based on his Gleason scores remaining in the “gray zone” below 10, the cancer

was low grade and confined to the prostate. After late 2017, the cancer cells began to mutate and

        3
        Instead, Dr. Korkowski’s letter to Collins informed him only that he had BPH and that
he should retest his PSA within four to six months.
                                              -4-
became more aggressive, as reflected in the higher January 2018 PSA levels, and they became a

high-grade Gleason 9 cancer. Dr. Huang reviewed the pathology slides from Collins’s surgery

and discovered a small percentage of highly aggressive small cell neuroendocrine carcinoma

cells among the more common adenocarcinoma cells. Dr. Huang disagreed that a prostate

cancer’s Gleason score is fixed from the time it first develops. Thus, he opined that if Collins’s

cancer had been treated with surgery or radiation in 2016 and 2017, he would have been cured.

               B. Defense’s Evidence

       Dr. Korkowski presented testimony from three experts: Dr. Jason Engel, Dr. Marc

Garnick, and Dr. Mark Markowski. Dr. Engel, a urologist, testified that Dr. Korkowski did not

breach the standard of care by monitoring Collins’s PSA levels for trends between 2016 and

2018 rather than referring him to a urologist. Dr. Engel opined that a biopsy is not necessarily

appropriate when a PSA level is between 4 and 10 ng/mL, but once Collins’s PSA rose to 14.52

ng/mL in May 2018, Dr. Korkowski complied with the standard of care by referring Collins to a

urologist.

       Dr. Garnick, a urologic oncologist, testified that an earlier diagnosis in 2016 would not

have altered Collins’s prognosis because Collins always had high-grade, Gleason 9 cancer.

Moreover, he stated that he knew of no studies or medical literature demonstrating a correlation

between rising PSA levels and a higher Gleason score.

       On cross-examination, Collins questioned Dr. Garnick about the value of PSA screening in

predicting prostate cancer outcomes. Dr. Garnick answered that “whether or not PSA-based testing

can lead to an earlier diagnosis, and if that earlier diagnosis can lead to improvements, as measured

by patients living longer . . . has been the subject of many, many different studies,” and “the

answers have been negative.”

                                                 -5-
       On redirect, Dr. Korkowski questioned Dr. Garnick further about the studies he cited

during cross-examination and presented them to Dr. Garnick without objection. When

Dr. Garnick began to address the advances in colon cancer screening, Collins objected that

Dr. Garnick was addressing “an area that was not raised . . . in cross-examination” and that he

was “going off on a[] . . . tangent that we didn’t discuss in cross.” Dr. Korkowski responded that

Collins had asked Dr. Garnick during cross-examination about “whether earlier prognosis could

lead to improvement of outcomes,” leading to Dr. Garnick citing certain “studies.”

Dr. Korkowski maintained that he was “simply following up with him on redirect.” Collins

offered no further argument, and the trial court overruled his objection. Dr. Garnick concluded

his testimony by noting that the studies he referenced supported his opinion that Collins’s

prognosis would have been no different if his cancer had been detected in 2016 or 2017.

       Dr. Markowski, an oncologist, also opined that, had Collins’s prostate cancer been

diagnosed in 2016 or 2017, Collins’s prognosis would have been the same. Like Dr. Garnick,

Dr. Markowski stressed that Gleason scores do not increase over time. In Dr. Markowski’s

opinion, Collins’s cancer was already a Gleason 9 in 2016, as reflected in Collins’s first elevated

PSA test results, but his PSA remained stable until January 2018 because it was suppressed by

his low testosterone levels. Dr. Markowski explained that prostate cancer, “particularly

metastatic prostate cancer,” is “fundamentally addicted to testosterone during its growth phase,”

but when testosterone levels drop, PSA levels drop and “the tumors shrink.” He noted that,

eventually, despite the low testosterone levels, the cancer starts growing again, and PSA levels

rise. He explained that the term used to describe prostate cancer at that stage is “castration

resistance.”

       In Dr. Markowski’s opinion, Collins’s PSA levels remained relatively stable until 2018

because his testosterone levels were low, but in 2018, his cancer became castration resistant,

                                                -6-
resulting in accelerated cancer growth and higher PSA levels. In support of his opinion,

Dr. Markowski cited the fact that Collins was prescribed Lupron following his prostate surgery

to lower his testosterone levels, but despite the treatment, his PSA levels rose, indicating he was

“already . . . castration resistant.” Dr. Markowski stressed that Collins’s lack of response to

Lupron was unusual because “[a]lmost everybody” responds initially to that treatment, with

patients continuing to respond, on average, “two to three years.” He noted that Collins’s

testosterone levels were low when tested in 2007 and likely remained low, as evidenced by his

erectile dysfunction and gynecomastia. Dr. Markowski therefore attributed Collins’s rising PSA

levels in January 2018 to castration resistance rather than to his cancer’s evolution from a low-

grade to a high-grade cancer.

               C. Proposed Rebuttal Testimony

       After Dr. Korkowski rested, Collins attempted to present rebuttal expert testimony from

Drs. Siddiqui and Huang to challenge Dr. Markowski’s opinion that Collins’s PSA remained

relatively stable until 2018 because his testosterone levels were low and then increased because

his cancer became castration-resistant. Collins proffered that his “rebuttal witnesses [would] put

on evidence that this testosterone level was not anywhere near low enough to have controlled the

PSA values and had nothing to do with the fact that these were stable in 2016 and 2017.” He

also proffered that the witnesses would refute defense evidence that Collins’s PSA levels rose in

2018 because his cancer became castration-resistant.

       Dr. Korkowski objected that Collins had not identified the proposed opinion in his

pre-trial designation. Collins responded that he could not “anticipate every piece of evidence”

that Dr. Korkowski would present and that Dr. Markowski’s specific opinion was not recited in

Dr. Korkowski’s “general designation” of Dr. Markowski’s opinion. Dr. Korkowski disagreed

and maintained that Dr. Markowksi’s opinion “was properly designated.” He emphasized that

                                                -7-
his designation “state[d] that Dr. Markowski is expected to testify that Mr. Collins had low

testosterone levels and how prostate cancer grows in a low testosterone environment.

Dr. Markowksi is expected to testify how this contributed to Mr. Collins’s cancer becoming

hormone refractory.” Dr. Korkowski asserted that Collins had been on notice of the opinion

since May 2022 but had not designated a rebuttal opinion to address it. Dr. Korkowski conceded

that Dr. Huang had been “designated to say when castration resistance happened,” but the

opinion was “very generic.”

       Initially, Collins did not dispute Dr. Korkowski’s assertion that his rebuttal designation

omitted the proposed rebuttal opinions. Collins simply maintained that he could not “counter

every opinion” in his rebuttal designation and that “fairness” required the admission of expert

testimony on rebuttal challenging the defense opinion that Collins’s low testosterone levels

explained his stable PSA levels. After the trial court ruled that the proposed rebuttal testimony

was inadmissible because it had not been designated, Collins asserted that “Dr. Huang’s opinion

with respect to castration resistance [wa]s designated.” The trial court reviewed the designation

and noted that it stated that Dr. Huang would testify that “[Collins] did not have castration

resistant prostate cancer at the time of surgery, but he does now.” The trial court stressed that

“that comment [wa]s made in the course of a discussion” that was not the basis for that opinion

and the designation did not include the grounds for the opinion. Accordingly, the trial court

concluded that the designation was insufficient.

               D. Verdict and Post-Verdict Motions

       The jury returned a verdict in favor of Dr. Korkowski and Loudoun Medical Group.

Collins filed a motion to set aside the verdict and for a new trial. In the motion, Collins

reiterated that his rebuttal designation was sufficient with respect to Dr. Huang and that, in any

                                                -8-
event, he was not required to designate rebuttal expert opinion under existing Virginia law.4 He

suggested that he anticipated Dr. Markowksi’s testimony, stressing that he designated the

opinion “to rebut Dr. Markowski’s theory of an aggressive cancer to start, slowed by a low

testosterone level (cancer cells feed off of testosterone), and then becoming more aggressive as

castration-resistant prostate cancer.” Nevertheless, he disputed Dr. Korkowski’s assertion that he

had sufficient opportunity to explore Dr. Markowski’s opinion during the latter’s deposition

because his rebuttal designation was due two days before the deposition.

       Following a hearing, the trial court denied the motion. On October 31, 2022, the trial

court entered final judgment in favor of Dr. Korkowski and Loudoun Medical Group. Collins

appeals.

                                            ANALYSIS

                                    I. Rebuttal Expert Testimony

       Collins asserts that the trial court erred by excluding his proposed rebuttal expert

testimony from Drs. Huang and Siddiqui. He contends that the proposed rebuttal expert

testimony was admissible because it was sufficiently identified in his pre-trial designation.

Collins further argues that, even if his designation was inadequate, he was not required to

disclose rebuttal expert opinion in his pre-trial designation because Dr. Korkowski never asked

       4
           In his motion, Collins cited his full designation of Dr. Huang’s expected testimony:

                 Mr. Collins did not have castration resistant prostate cancer at the
                 time of surgery, but he does now. The typical treatment course is
                 that the prostatectomy occurs first and then the patient is provided
                 hormonal therapy, which would provide temporary disease control.
                 When the tumor recurs after the therapy, it can cause
                 castration-resistant prostate cancer. Dr. Huang is of the opinion
                 that the cancer in the cul-de-sac of the peritoneum, the bilateral
                 seminal vesicles, and the right vas deferens, plus in 4 out [of] 10
                 lymph nodes, would be considered significant metastasis which
                 developed between January of 2018 and October of 2018.
                                                  -9-
him to disclose rebuttal experts in discovery, and the pre-trial order limited his designation

requirement to expert opinions requested in discovery. Moreover, citing authority from another

jurisdiction, Collins maintains that, where “a defendant introduces evidence of an affirmative

matter in defense or justification,” the plaintiff is entitled to present rebuttal evidence “as a

matter of right.”5 Finally, he asserts that the trial court’s exclusion of the evidence deprived him

of his constitutional right to a fair trial.6

           We review a trial court’s “ruling on the admissibility of testimony, whether expert or lay,

. . . for an abuse of the court’s discretion.” Emerald Point, LLC v. Hawkins, 294 Va. 544, 553

(2017). “[W]hen the issue is whether a fact or opinion which is the subject of expert testimony

has been adequately disclosed in response to a proper discovery inquiry under Rule

4:1(b)(4)(A)(i), the ‘application of this rule begins with determining whether the opinion at issue

was disclosed in any form.’” Id. (quoting John Crane, Inc. v. Jones, 274 Va. 581, 591 (2007)).

Under Rule 4:1(b)(4)(A)(i), an expert witness designation “must . . . disclose the ‘substance of

the facts and opinions to which the expert is expected to testify and a summary of the grounds for

each opinion.’” Id. (quoting Rule 4:1(b)(4)(A)(i)).7 Thus, in John Crane, the Supreme Court

affirmed the exclusion of expert testimony when the defendant identified the topic, but not the

substance, of the expert’s opinion. 274 Va. at 592.

           Collins acknowledges the disclosure requirements for expert opinions in John Crane and

Rule 4:1(b)(4)(A)(i), but he contends that the trial court erred by excluding his rebuttal expert

           5
       Collins cites Astill v. Clark, 956 P.2d 1081, 1086 (Utah 1988), in support of this
argument.
           6
         In a separate assignment of error, Collins contends that the exclusion of the evidence,
standing alone, or in combination with the other errors assigned on appeal, deprived him of due
process. We address his constitutional arguments in connection with that assignment of error.
           7
               Rule 4:1(b)(4)(A)(i) has been amended since 2017, but the cited language was not
altered.
                                                   - 10 -
testimony for two reasons. First, Collins asserts that his pre-trial designation adequately

disclosed, at least with respect to Dr. Huang, that Collins would present expert testimony

addressing whether his low testosterone controlled his PSA levels. Second, Collins suggests

that, even assuming that the designation was insufficient, Dr. Korkowski’s expert designation

was too vague to place him on notice that Dr. Markowski would opine that Collins’s low

testosterone modulated his PSA in 2016 and 2017. Collins contends that a plaintiff cannot

foresee every nuance of defense expert testimony and, therefore, a plaintiff is entitled, as a matter

of right, to challenge the defendant’s expert testimony through rebuttal expert testimony,

regardless of whether the rebuttal expert testimony was disclosed before trial. Collins also notes

that he lacked the opportunity to depose Dr. Markowski before his rebuttal designation was due.

       The disclosure requirement in Rule 4:1(b)(4)(A)(i) is intended “to ‘allow the litigants to

discover the expert witnesses’ opinions in preparation for trial.’” Condo. Servs., Inc. v. First

Owners’ Ass’n of Forty Six Hundred Condo., Inc., 281 Va. 561, 576 (2011) (quoting Woodbury

v. Courtney, 239 Va. 651, 654 (1990)). An expert witness disclosure is insufficient unless it

reveals both the topic and the substance of the proposed expert testimony. John Crane, 274 Va.

at 591-92. “It [i]s within the discretion of the [trial] court to determine whether the [disclosure]

sufficiently disclose[s] the subject matter on which [the expert] [i]s going to testify, the

substance of [his] opinions and a summary of the grounds for [his] opinions.” Condo. Servs.,

281 Va. at 576. When the expert disclosure contains only a passing reference to a topic, the trial

court abuses its discretion by admitting expert testimony. See Emerald Point, 294 Va. at 554

(holding that a trial court erred in admitting an expert’s testimony regarding dementia, where the

expert disclosure contained only a single reference to dementia).

       Here, the pre-trial scheduling order required that, if Collins’s expert witnesses were

requested during discovery, Collins had to identify them 90 days before trial. Dr. Korkowski, in

                                                - 11 -
turn, was required to identify his expert witnesses 60 days before trial. Further, the pre-trial

scheduling order stated that “[i]f requested in discovery, experts or opinions responsive to new

matters raised in the opposing parties, identification of experts shall be designated no later than

45 days before trial.” The order also stated,

               If requested, all information discoverable under Rule
               4:1(b)(4)(A)(i) of the Rules of Supreme Court of Virginia shall be
               provided or the expert will not ordinarily be permitted to express
               any nondisclosed opinions at trial. The foregoing deadlines shall
               not relieve a party of the . . . duty to supplement or amend prior
               responses pursuant to Rule 4:1(e).

       Scheduling orders “facilitate the orderly administration of cases” and “must be enforced

by the trial courts.” Reaves v. Tucker, 67 Va. App. 719, 732 (2017); see also Rule 1:18. “There

is little point in issuing such orders if they amount to nothing more than a juristic bluff—obeyed

faithfully by conscientious litigants, but ignored at will by those willing to run the risk of

unpredictable enforcement.” Rahnema v. Rahnema, 47 Va. App. 645, 658 (2006). “The

impartial, consistent enforcement of scheduling orders provides systemic benefits to litigants and

trial courts alike.” Id. “Because the timing of the duty to disclose expert opinions can

sometimes lead to insufferable arguments over who knew what when and why it took so long to

disclose it, courts use pretrial scheduling orders to mark the outer boundaries of the disclosure

duties.” Mikhaylov v. Sales, 291 Va. 349, 358 (2016).

       Here, the pre-trial scheduling order provided that, “if requested, all information

discoverable under Rule 4:1(b)(4)(A)(i)” had to be disclosed before trial. The order specifically

warned that “all information discoverable under Rule 4:1(b)(4)(A)(i) of the Rules of Supreme

Court of Virginia shall be provided or the expert will not ordinarily be permitted to express any

nondisclosed opinions at trial.” (Emphasis added). Rule 4:12(b)(2) empowers a trial court to

“sanction a party that ‘fails to obey an order to provide or permit discovery.’” Galloway v. Cnty.

of Northampton, 299 Va. 558, 563 (2021) (quoting Rule 4:12(b)(2)). One available sanction “is
                                                - 12 -
to prohibit an offending party ‘from introducing designated matters in evidence,’ including by

preventing the party’s witness from testifying.” Id. (quoting Rule 4:12(b)(2)(B)).

       The trial court interpreted the expert designation requirement to include rebuttal experts.

See Davis v. Commonwealth, 70 Va. App. 722, 732 (2019) (“[T]rial courts have the authority to

interpret their own orders.” (alteration in original) (quoting Fredericksburg Const. Co. v. J.W.

Wyne Excavating, Inc., 260 Va. 137, 144 (2000))). Given his extensive designation of rebuttal

expert testimony, it is apparent Collins interpreted the designation requirement similarly.

Although he now asserts that the pre-trial scheduling order did not apply to rebuttal experts

because Dr. Korkowski did not request that information during discovery, Collins did not make

that argument to the trial court at the time it ruled on Dr. Korkowski’s objection. The first time

Collins made that argument was in a supplement to his motion to set aside the verdict. As such,

it was no longer timely. See Bitar v. Rahman, 272 Va. 130, 139 (2006) (“[A]n objection [as] to

the admissibility of evidence must be made when the evidence is presented.” (quoting

Kondaurov v. Kerdasha, 271 Va. 646, 655 (2006))).

       Further, the trial court did not abuse its discretion by ruling that Collins did not designate

the proposed rebuttal opinion testimony in Dr. Huang’s designation. Although Collins asserts

that the reference to castration resistance in Dr. Huang’s designation addressed the relationship

between Collins’s testosterone and PSA levels from 2016 to 2018, nothing in the designation

relates castration resistance to Collins’s PSA levels during that time frame. Even if the castration

resistance reference pertained to Collins’s PSA levels, the trial court could reasonably construe

the reference, read in context with the rest of the paragraph, as referring to the “typical treatment

course” for prostate cancer, not to rebut the defense theory that Collins’s low testosterone levels

stabilized his PSA scores until 2018. As the trial court observed, “[I]t seems that . . . that

comment is made in the course of a discussion, that part of that discussion isn’t his basis for

                                                - 13 -
having that opinion.” The trial court ruled that Collins’s rebuttal designation did not encompass

the proposed rebuttal testimony that his testosterone levels were not low enough to control his

PSA scores.8 It thus concluded that Collins’s rebuttal designation did not sufficiently disclose

the subject matter of the proposed rebuttal expert testimony, the substance of the opinion, and a

summary of the grounds for the opinion. Condo Servs., 281 Va. at 576. In so concluding, the

trial court found that Dr. Huang’s designation did not comply with the requirements of the pre-

trial scheduling order and that such noncompliance justified exclusion of the rebuttal testimony.

Accordingly, we find no abuse of discretion in the trial court’s decision. See Reaves, 67

Va. App. at 736 (finding no abuse of discretion in a trial court’s decision to “uphold the

scheduling order by denying [the party] permission to present any witnesses or exhibits that had

not been disclosed prior to trial”).

        As the trial court found Collins’s rebuttal expert designation inadequate, we consider

whether any “legitimate reason” justified his failure to provide an adequate designation.

Mikhaylov, 291 Va. at 360 (absent a “legitimate reason” justifying the failure to disclose an

expert opinion before trial, the trial court erred by admitting the previously undesignated opinion

at trial). In ruling on Dr. Korkowski’s objection, the trial court noted that “the opinion [of

Dr. Markowski regarding the relationship between low testosterone and PSA test results] was not

or should not have been a surprise as it was designated by the [defendants].” Although Collins

maintains that he did not have the opportunity to depose Dr. Markowski before Collins’s

designation deadline, Collins never supplemented his designation after the deposition.

        8
         On appeal, Collins asserts that “Dr. Siddiqui’s rebuttal designation is replete with
references to opinions that he would offer regarding the progression of Mr. Collins’ cancer from
low risk, to intermediate risk, and then to high risk . . . [from] 2016 through 2018.” However,
Collins did not argue below that his rebuttal designation was sufficient with respect to
Dr. Siddiqui. Accordingly, to the extent that he advances that argument on appeal, he has failed
to preserve it. Rule 5A:18. Collins does not invoke any exception to Rule 5A:18, and we will
not invoke an exception sua sponte. Williams v. Commonwealth, 57 Va. App. 341, 347 (2010).
                                                - 14 -
       In City of Hopewell v. County of Prince George, 240 Va. 306, 314-15 (1990), the

Supreme Court affirmed the trial court’s exclusion of a rebuttal expert’s testimony because the

plaintiff had failed to list the rebuttal expert in its pre-trial designation. The Supreme Court

rejected the plaintiff’s assertion that “it could not reasonably have anticipated the need for [the

rebuttal expert]’s testimony” until after it had deposed the defense expert it sought to rebut. Id.

at 314. The Court stressed that, even though the plaintiff had not deposed the defense expert

before the March 1989 deadline for identifying its witnesses, the plaintiff did depose the defense

expert in April 1989 before the September 1989 trial date. Id. Despite taking the defense

expert’s deposition and despite the defendant’s July 1989 interrogatory response summarizing

the defense expert’s testimony, the plaintiff “waited until almost the eve of trial to identify [its

rebuttal expert] as a prospective witness.” Id.

       Similarly, Collins’s lack of opportunity to prepare an adequate designation seems to be

one of his own making. Dr. Korkowski initially designated Dr. Markowski’s opinion on April

29, 2022, before trial began on June 27, 2022. The pre-trial scheduling order permitted

depositions up until 30 days before trial. Although not indicated in the record, Collins

acknowledges on brief that he took Dr. Markowski’s deposition on May 17, 2022—two days

after the deadline for designating his rebuttal witnesses. Collins does not state whether

Dr. Markowski revealed his opinion on the effect of Collins’s low testosterone during his

deposition. At trial, Collins never claimed that he was surprised by Dr. Markowski’s testimony,

noting only that the defense designation was not very specific. In his post-verdict motion,

Collins suggested that he prepared his rebuttal designation in anticipation of Dr. Markowski’s

testimony.9 But Collins never supplemented his expert witness designation after May 17, 2022.

       9
        At the hearing on his post-verdict motion, Collins argued that “nothing” in
Dr. Markowski’s designation addressed the significance of Collins’s low testosterone levels as
                                             - 15 -
Thus, we hold that the trial court did not abuse its discretion by refusing to allow Collins to

present rebuttal expert testimony about low testosterone and PSA because Collins failed to

designate such testimony as required by the pre-trial scheduling order.

                                     II. Deposition Testimony

       Collins maintains that the trial court erred by allowing Dr. Korkowski to play certain

excerpts of Collins’s videotaped deposition at trial. Collins neither identifies where in the record

the excerpts were admitted nor describes their content. Nevertheless, he asserts that the trial

court erred by admitting the excerpts because Dr. Korkowski did not provide him with specific

page and line references of the excerpts until the morning of trial. Further, Collins contends that

the trial court erred by refusing to permit him to “cross-designate” other portions of the

deposition for admission. Citing Rule 4:7(a)(5), Collins argues that he was entitled to introduce

other excerpts because Dr. Korkowski read only a portion of Collins’s deposition.10

       At trial, Collins objected to the admission of excerpts from his deposition because they

were not disclosed before trial and because he should be permitted to “cross-designate” portions

of the deposition. Dr. Korkowski responded that Rule 4:7(a)(3) permits the use of a party

deposition by an adverse party for any purpose and without any disclosure requirement.

Dr. Korkowski also stressed that the pre-trial scheduling order only required the pre-trial

disclosure of depositions to be used at trial if they were from non-parties, not parties such as

Collins. The trial court overruled Collins’s objection and permitted Dr. Korkowski to play the

deposition excerpts. Collins never proffered his “cross-designation.”

they related to his PSA. Collins did not, however, object to Dr. Markowski’s testimony, nor did
he claim that he was surprised by it.
       10
         Rule 4:7(a)(5) states: “If only part of a deposition is offered in evidence by a party, an
adverse party may require him to introduce any other part which ought in fairness to be
considered with the part introduced, and any party may introduce any other parts.”
                                               - 16 -
       On appeal, Collins’s sole argument is that Dr. Korkowski did not provide him with

sufficient advance notice that the excerpts would be introduced, thereby hampering Collins’s

ability to prepare a cross-designation. Collins does not claim that the admission of the excerpts

otherwise prejudiced him.11 Because his sole argument is that the untimely identification of the

excerpts prejudiced his ability to present a cross-designation, we conclude that he waived his

argument by failing to proffer a cross-designation.

       “It is well established that a party who wishes to challenge the trial court’s exclusion of

evidence on appeal must provide a proffer of that evidence that is adequate to permit this Court

to determine whether the lower court erred.” Smith v. Commonwealth, 72 Va. App. 523, 541

(2020). “When trial testimony is excluded before it is delivered, an appellate court lacks a basis

for reviewing a [trial] court’s evidentiary ruling unless the record reflects a proper proffer.”

Graham v. Cook, 278 Va. 233, 249 (2009). An appropriate proffer creates a record of “what the

[evidence] would have been.” Holles v. Sunrise Terrace, Inc., 257 Va. 131, 135 (1999). In this

regard, the proffer provides a complete record for review. Wyche v. Commonwealth, 218 Va.

839, 843 (1978). The proffer also allows an appellate court to determine whether the exclusion

of the evidence prejudiced a party. Graham, 278 Va. at 249. “Absent a proffer showing ‘harm

was done,’ we are ‘forbidden to consider the question.’” Ray v. Commonwealth, 55 Va. App.

647, 650 (2010) (quoting Scott v. Commonwealth, 191 Va. 73, 78-79 (1950)).

       Although he contends that he lacked sufficient time to prepare a proffer immediately after

Dr. Korkowski introduced the deposition excerpts, Collins never submitted a proffer before the

evidence closed or in a post-verdict motion. Accordingly, as Collins never proffered the

proposed deposition testimony, we are unable to address his argument that the trial court

       11
         Without a record of the admitted excerpts, we would be unable to address whether their
admission prejudiced Collins.
                                             - 17 -
committed reversible error by excluding it. See Molina v. Commonwealth, 47 Va. App. 338, 368

(2006) (stating that a sufficient proffer allows the appellate court to examine both the

admissibility of the proposed evidence and whether, assuming the evidence was admissible, its

exclusion prejudiced the proffering party).

                                     III. Redirect Testimony

       Collins asserts that the trial court erred by permitting Dr. Korkowski to question

Dr. Garnick on redirect about medical literature concluding that PSA tests were not useful in

altering treatment outcomes for prostate cancer patients. He maintains that the redirect was

improper because “this line of questioning was not raised [during] cross-examination.” Further,

Collins contends that the trial court erred by refusing to allow him to cross-examine Dr. Garnick

a second time following redirect.

       We review a trial court’s decision regarding the proper scope of examination for abuse of

discretion. Castillo v. Commonwealth, 70 Va. App. 394, 461 (2019); Commonwealth v. Swann,

290 Va. 194, 199 (2015). “Under ‘the American rule’ applied in this Commonwealth, the

cross-examination of a witness is limited to matters elicited on direct examination.” Smith v.

Irving, 268 Va. 496, 501 (2004). And it is well-established that where new matters are drawn

out of a witness during cross-examination, an attorney is permitted to address the same subject

on redirect. See Scholz v. Stand. Acc. Ins. Co., 145 Va. 694, 720 (1926) (“A party who has

voluntarily brought out evidence on the cross-examination of a witness, will not be heard to

object to the same evidence when brought out by his adversary on a re-examination of the same

witness.”). Accordingly, in assessing whether the trial court abused its discretion by permitting

Dr. Korkowski’s redirect examination on certain medical literature, we focus on whether Collins,

the cross-examining party, “opened the door” to the subject during cross-examination. Swann,

290 Va. at 200.

                                               - 18 -
       During cross-examination, Collins asked Dr. Garnick whether PSA tests had any value in

predicting prostate cancer outcomes, and Dr. Garnick answered that “[t]hat specific

question . . . has been the subject of many, many different studies” and that the studies have

concluded that PSA tests were not helpful in that regard. Because Dr. Garnick addressed these

“studies” during cross-examination, the record shows that Collins opened the door to that

subject, entitling Dr. Korkowski to explore the studies further on redirect examination.12 Thus,

the trial court did not abuse its discretion by allowing Dr. Korkowski to question Dr. Garnick on

redirect about the medical literature supporting Dr. Garnick’s opinion regarding the value of PSA

tests in altering the outcome of high-grade prostate cancers.

       Moreover, Collins never asked the trial court for permission to conduct additional

cross-examination; therefore, the trial court never ruled on that issue.13 Where a party fails to

obtain a ruling on a matter presented to a trial court, there is nothing for this Court to review on

appeal, and the “argument is waived under Rule 5A:18.” Williams v. Commonwealth, 57

Va. App. 341, 347 (2010) (quoting Fisher v. Commonwealth, 16 Va. App. 447, 454 (1993)).

Collins does not ask that we consider his argument under an exception in Rule 5A:18, and we

will not invoke an exception sua sponte. Id. Accordingly, we decline to address Collins’s

assertion that the trial court erred by refusing to allow him to conduct further cross-examination

of Dr. Garnick.

       12
            Notably, Collins did not move to strike Dr. Garnick’s testimony as non-responsive.
       13
         Even if Collins had requested further cross-examination, he never proffered the
testimony he hoped to elicit on cross-examination. Without such a proffer, we would be unable
to determine whether Collins was prejudiced by the trial court’s ruling.
                                             - 19 -
                                           IV. Due Process

        Collins contends that the trial court’s errors, separately or in combination, deprived him

of due process and his right to a fair trial. Collins’s constitutional arguments hinge on whether

the trial court committed error.14 Because we find no error in the trial court’s rulings, we

conclude that Collins’s constitutional arguments likewise lack merit.

                                           CONCLUSION

        For the reasons stated, the trial court’s judgment is affirmed.

                                                                                              Affirmed.

        14
          To the extent that Collins asserts he had a constitutional right to present rebuttal
evidence, regardless of whether he complied with his discovery and pre-trial order obligations,
he cites no authority supporting such an argument, as required by Rule 5A:20(e). Further, he
offers no legal authority holding that evidentiary rulings otherwise comporting with rules of
court or court orders are unconstitutional. We find that Collins’s failure to comply with Rule
5A:20 is significant; therefore, to the extent he advances these arguments, we decline to consider
them. See Fadness v. Fadness, 52 Va. App. 833, 851 (2008) (“If the parties believed that the
circuit court erred, it was their duty to present that error to us with legal authority to support their
contention.”).
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